ACKNOWLEDGEMENTSassets.fsnforum.fao.org.s3-eu-west-1.amazonaws.com/public/files/9… · CBN...

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ACKNOWLEDGEMENTS

This publication was developed by Concern Worldwide Ethiopia in collaboration with Dessie Zuria

Woreda and the Government of Ethiopia. It was made possible through funding from Alive & Thrive

provided by FHI 360. Printing was carried out with the aid of a grant from the Micronutrient

Initiative, Ottawa, Canada, through the financial assistance of the Government of Canada, Canadian

International Development Agency (CIDA).

We would also like to express our sincere gratitude to the following contributors for their valuable

assistance and efforts in reviewing and finalising this training package.

1. Lioul Berhanu

2. Joy Desta Brandsma

We also acknowledge Le Monde Health and Development consultancy PLC for actively participating

in the development and pre-testing of the training module. Finally, we would like to acknowledge

Concern Worldwide head office and field staff who supported the development and pre-testing of

this material, and Siobhán Sheerin for design and editing.

July 2012

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FOREWORD

Considerable effort has been made in Ethiopia in recent years to address the problem of food

insecurity, to great success, and the current programmes cover a large number of the 8 million food

insecure population. These include initiatives such as the Productive Safety Net Programme (PSNP),

which lies within the Government of Ethiopia’s Food Security Programme (FSP) – a key pillar of

Ethiopia’s Food Security Strategy.

However, the linkages between the different systems which aim to identify household beneficiaries

are still lacking. It’s difficult to know when a PSNP beneficiary is also a beneficiary of targeted

supplementary feeding (TSFP), for example. Therefore, there is an urgent need to strengthen the

links between the various programmes affecting nutrition and food security.

This guide offers a concrete example of the way in which nutrition programmes, such as Infant and

Young Child Feeding (IYCF), can be integrated with existing government programmes in order to

improve health and nutrition outcomes for children, especially infants under the age of 2 years.

Infant and young child feeding practices are poor overall in Ethiopia and in Amhara region in

particular. The Ethiopia Demographic and Health Survey 2011 found that just over half (51.5%) of

children are breastfed within one hour of birth (37.5% in Amhara region), which falls short of the

Health Sector Development Program IV target of 92%. Additionally, there is poor dietary diversity

and low meal frequency, with only 4.3% of children eating foods from four or more groups (2.1% in

Amhara), and less than half eating the minimum number of meals per day (34.0% in Amhara).

This valuable training guide shows ways in which IYCF programming can be integrated into the

existing PSNP, thus creating much-needed linkages between programmes and helping to address the

underlying causes of malnutrition.

Ato Gezahegn Tamire

Senior Nutrition Officer

Amhara Regional Health Bureau

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TABLE OF CONTENTS

Acknowledgements i

Foreword ii

Table of Contents iii

Acronyms iv

Introduction v

Session One: Introduction to the training 1

Session Two: Addressing malnutrition in the context of PSNP 8

Session Three: Overview of IYCF and PSNP programmes 13

Session Four: Optimal breastfeeding practices 17

Session Five: Optimal complementary feeding practices 25

Session Six: Feeding of sick child and referral linkage to CMAM and other services 41

Session Seven: Women’s nutrition 46

Session Eight: Behaviour change communication and counselling skills 53

Session Nine: Community based information systems 64

Session Ten: Action planning 70

References 75

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ACRONYMS

BF Breast Feeding

BCC Behavioural Change and Communication

CBIS Community-Based Information System

CBN Community-Based Nutrition

CCI Complementary Infrastructure Complementary Community Infrastructure

CF Complementary Feeding

CMAM Community-Based Management of Acute Malnutrition

DA Development Agents

ENA Essential Nutrition Action

FSP Food Security Programme

HABP Household Asset-Building () Household Asset-Building Programme

FSTF Food Security Task Force

HEW Health Extension Worker

HEP Health Extension Programme

HO Hand Out

IEC Information, Education and Communication

IYCF Infant and Young Child Feeding

KFSTF Kebele Food Security Task Force

LHD Le Monde Health and Development

PSNP Productive Safety Net Programme

TIPs Trials of Improved Practices

TSFP Targeted Supplementary Feeding Programme

TOT Training of Trainers

VCHW Voluntary Community Health Workers

WFSTF Woreda Food Security Task Force

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INTRODUCTION

According to MDG UNDP progress report 2009/10, the under-five mortality rate decreased from

123/1000 live births in 2005/06 to 101/1000 and infant mortality rate decreased from 77/1000 in

2005/06 to 45/1000. This change is based on an increased coverage of maternal, newborn and child

health, nutrition and WASH related interventions. Some of these interventions include exclusive

breastfeeding up to 6 months of age, hand washing with soap, and micronutrient supplementation;

preventative measures such as immunization; and curative measures such as prompt community

based treatment of diarrhoea, malaria, pneumonia and severe malnutrition. In order to maintain this

achievement, nutrition programmes focusing on malnutrition prevention need critical attention.

Two years ago, Concern Worldwide documented the poor nutritional situation in Dessie Zuria

Woreda and the multiple obstacles hampering previous efforts to improve it. It concluded that a

multi-sectoral approach to improve optimal infant and young child feeding (IYCF) practices and to

increase access to food were among the responses needed. The programme targets poor

households enrolled in the existing PSNP as well as the general population and address both the

direct and root causes of malnutrition.

This Productive Safety Net Programme (PSNP) /Infant and Young Child Feeding (IYCF) Practices

facilitator’s guide is intended to equip Woreda food security task force members with basic hands-

on skills for incorporating the IYCF approach into PSNP. After undertaking this training, participants

are expected to facilitate training for Kebele food security task force members.

Training Agenda

The three day training is organised in a sequence which facilitates learning and practice at Woreda

and Kebele level. The health and PSNP programme at Woreda and Kebele level will support

mothers/caregivers enrolled as PSNP beneficiaries in the prevention of undernutrition. Each day’s

session outlines specific learning objectives, activity details, materials/handouts (HOs) and

methodologies for learning activities. The sessions are based on the major components of optimal

IYCF practices and all sessions have knowledge and skill components. The roles of individual

members of the food security task force are expected to be discussed and outlined at the end of

each session. The community volunteers will apply the knowledge and skills to help

mothers/caregivers optimally feed their infants and young children, and to care for their own

nutritional needs.

Training Methodology

The training capitalises on participants’ own experiences and the sessions aim to be relevant to the

needs of participants and their communities. The participatory training approach uses the

experiential learning cycle method and prepares participants for hands-on work. The course employs

a variety of training methods: demonstrations, practice, discussions, case studies, group discussion,

and role play. Participants also act as resource persons for each other. Participants benefit from

community practice, working directly with mothers, pregnant women, and mothers/caregivers who

have young children. Respect for individual trainees is central to the training, and sharing of

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experiences is encouraged throughout. Participants complete pre- and post training assessment

questionnaires and discuss their evaluations at the end of the training.

Trainee Handouts

Each participant will receive handouts and job aids to facilitate the learning process throughout the

training. During the training the participants use existing Information, Education and Communication

(IEC) and Behavioural Change and Communication (BCC) materials and other available infant and

young child feeding visuals. Similarly, each participant will receive a counselling card which

summarises the key points on breastfeeding, complementary feeding and women’s nutrition.

Training Location

Wherever the training is planned, a community-based site should be readily available to support

working with mothers/ caregivers on practical PSNP and IYCF practices. The site will be prepared by

coordinating with Health Extension Workers (HEW) and Development Agents (DA) and/or

community before the arrival of participants. It is advised to have two facilitators for about 20-25

participants per each session.

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SESSION ONE: INTRODUCTION TO THE TRAINING

Objectives

At the end of this session the participants will:

Have got to know each other.

Understand the objectives and purpose of the training.

Be familiar with Concern Worldwide/Alive and Thrive Ethiopia IYCF Project.

Activity overview:

Activity 1.1: Welcome and opening remarks. (5 Minutes)

Activity 1.2: Introduction of participants and facilitators. (20 Minutes)

Activity 1.3: Establishing the ground rules. (5 Minutes)

Activity 1.4: Participants’ expectations. (5 Minutes)

Activity 1.5: Pre-test assessment. (10 Minutes)

Activity 1.6: Training overview and schedule. (5 Minutes)

Activity 1.7: Concern IYCF /PSNP Project. (10 minutes)

Total time: 60 Minutes

Materials needed

Flip chart stand, flipchart paper, marker, masking tape, blank cards, or name tags.

Training schedule.

Pre- test assessment .

HO 1A: Questions to discuss during participants’ introductions.

HO 1B: Goal and objectives of the training course.

HO 1C: Concern IYCF project overview.

Advance preparation

Identify representatives of local official or project staff for the formal opening.

Brief this guest on the purpose and objectives of the training, and time allocated for the opening

remark.

Prepare all the necessary materials the day before the training begins. Prepare name tags for

the participants and the trainers.

Make enough copies of the agenda and handouts for participants ready for distribution.

Prepare flipchart texts.

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Detail of activities

Activity 1.1: Welcome and opening remarks (5 Minutes)

Welcome participants and thank them for attending the course. Introduce yourself, other

facilitators and guests. Invite guest of honour to make an opening remark.

Activity 1.2: Introduction of participants and facilitators (20 Minutes)

Explain to the participants that we will be working as a team during the training, so we need to

know each other and feel comfortable communicating.

Show HO 1A and explain how each participant will introduce himself/herself.

Make a small paper ball. Ask the participants to stand up and make a circle. Start by throwing

the ball to one of the participants and ask them them to introduce themself based on HO 1A.

Give each person a piece of card/a name tag, and ask them to write their name on the tag or

card so that it can be folded in half and placed in front of their chair or clipped on their chest.

HO 1A: Questions for participant introduction

What is your name?

What would you like to be called during the course (name or nickname)?

Where do you come from? (Where do you live)?

What special talents or hobbies do you have?

Things you like and dislike?

Activity 1.3: Establishing the ground rules (5 Minutes)

Explain that we all will be working together for the duration of the training and that it would be

a good idea to establish some rules.

Ask the participants to suggest rules that can help us to run the training smoothly.

Write participants’ responses on the flipchart.

Put the flipchart with the ground rules on the wall so that everyone can see it during the course.

Choose and assign participants for recap, time keeping, energisers etc.

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Activity 1.4: Participants’ expectations (5 Minutes)

Ask participants what they expect from the training? Write responses on the flipchart.

Summarise participants’ responses.

Display HO 1B that shows the objectives of the training.

Compare with participants’ expectations.

HO 1B: Objectives of the training

Facilitator’s Tip

In alternating colours, write on the flipchart all suggestions, using participants’ own words. However,

consider rewriting the answers in positive terms, as needed. For example, if a participant says “Do

not be late,” consider rephrasing this as “Be on time.”

Some examples of ground rules:

Participate actively.

Respect each other’s opinions/ideas.

Speak one at a time.

Ask if not clear.

Put your cell phone on vibration mode /Turn off all cell phones.

Be supportive rather than judgmental.

General Objective

The purpose of this training is to equip PSNP and health care personnel with the knowledge and

skills needed to incorporate recommended IYCF practices into PSNP.

Objectives

At the end of their training, participants will be able to:

Briefly describe PSNP and IYCF programmes and show opportunities for linkages.

Explain how to utilise PSNP created opportunities for promotion of optimal IYCF

practices.

Explain optimal IYCF practices of pregnant and lactating women.

Describe their own role in helping mothers access diversified food items in their

community.

Use job aids to negotiate with mothers to adopt optimal IYCF practices.

Develop an action plan for what they will do when they return to the community.

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Briefly explain the purpose of the pre-test (below), saying it helps participants and facilitators to

identify areas or topics they need to give emphasis to during the training.

Distribute pre-test questions to participants and collect after 10 minutes. Remind them when

there are 5 minutes are left.

Tell participants that there will be written training evaluation at the end of the training.

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Activity 1.5: Pre-test assessment (10 Minutes) PSNP/IYCF: pre and post test

# Pre-Test Yes No

1. Decreasing malnutrition is wholly the responsibility of the health office/HEWs.

2 PSNP by itself solves the problem of malnutrition.

3 Food insecurity is the only cause of malnutrition.

4 Undernutrition of children can be addressed by collaborative efforts of all sectors.

5 It is good to start breast feeding immediately after birth.

6 Exclusive breastfeeding with water is important for the child up to the age of 6

months.

7 When the infant is 4 months old, a mother should begin giving her baby foods in

addition to breast milk.

8 Women’s work load has an effect on maternal nutritional status.

9 Watery gruel is a better food for a baby 6 months old than soft and thick

porridge.

10 Availability and accessibility of food can support nutritional problems of mothers

and children completely.

11 Enriching food with oil and vegetables may not necessarily improve the

nutritional status.

12 A mother should not wait until the sick child is healthy before giving him/her

foods.

13 One counselling visit is enough to change the feeding behaviour of a mother.

14 Food security programmes in the Dessie Zuria Woreda are properly utilised to

promote better nutritional status of women and young children.

15 Data on IYCF/PSNP is not only needed for the purpose of reporting to Woreda

offices, but also for decision making at Kebele level.

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PSNP/IYCF: answers to pre-test

# Answers: Pre-Test Yes No

1. Decreasing malnutrition is wholly the responsibility of HEWs. x

2. PSNP by itself solves the problem of malnutrition. x

3. Food insecurity is the only cause of malnutrition. x

4. Undernutrition of children can be addressed by collaborative efforts of all

sectors.

X

5. It is good to start breast feeding immediately after birth. X

6. Exclusive breastfeeding with water is important for the child up to the age

of 6 months.

X

7. When the infant is 4 months old, a mother should begin giving her baby

foods in addition to breast milk.

X

8. Women’s work load has an effect on maternal nutritional status. X

9. Watery gruel a better food for a 6 month old baby than soft enriched

porridge.

X

10. Availability and accessibility of food can support the nutritional problems

of mothers and children completely.

X

11. Enriching food with oil and vegetables may not necessarily improve the

nutritional status.

X

12. A mother should not wait until the sick child is healthy before giving

him/her foods.

X

13. One counselling visit is enough to change the feeding behaviour of a

mother.

X

14 Food security programmes in the Dessie Zuria Woreda are properly utilised

to promote better nutritional status of women and young children.

X

15 Data on IYCF/PSNP is needed not only for the purpose of reporting to

Woreda offices, but also for decision making at Kebele level.

X

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Activity 1.6: Training overview and schedule (5 Minutes)

Distribute and read the training schedule/agenda and explain it briefly.

Explain any logistical issues.

Thank the participant for their active participation and let them break for tea and come back

after 20 minutes.

3-DAY AGENDA

SESSION TITLE DURATION

DAY 1

Session 1 Introduction: Why are we here?

Learning objectives/expectations

Pre-test

1 hour

Session 2 Addressing malnutrition in the context of PSNP 1:45 hour

Session 3 Overview of PSNP and IYCF 2:30 hours

Session 4 Optimal breastfeeding practices 2:30 hours

Daily summary 15 minutes

DAY 2

Daily recap 15 minutes

Session 4 cont. Optimal breastfeeding practices continued 1 hour

Session 5 Optimal CF feeding practices and cooking demonstration 5:30 hours

Session 6 Feeding of sick child and referral linkages 1 hour

Daily summary 15 minutes

DAY 3

Daily recap 15 minutes

Session 7 Women’s nutrition 1 hour 30 minutes

Session 8 BCC and counselling skills 2 hours

Session 9 CBIS and field visit 2:30 hours

Session 10 Action plan development 1 hour

Closing, post-test and final training evaluation 45 minutes

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Activity 1.7: Concern Worldwide/Alive and Thrive IYCF project (10 minutes)

Sumamrise HO 1C

Present the programme overview in plenary.

Complement by asking the programme manger in the area for their input.

HO 1C: Concern Worldwide/ Alive and Thrive IYCF project

The 24-month project aims to improve IYCF practices among PSNP beneficiaries. The approach

will be to work closely with the existing CBN and HEP efforts and give targeted support to HEWs

and VCHWs and their supervisors to strengthen BCC on IYCF, and linking households with

nutrition-focused services of DAs.

In particular, the project will work to ensure that these IYCF services are effectively delivered to

the most vulnerable households via PSNP through the use of different community contact points.

Changes occurring among this group are also to be monitored.

Capacity building will be a key approach and include training of HEWs/ VCHWs/ DAs and other

members of the food security task force on action points that help to incorporate IYCF approach

into PSNP. HEWs and VCHWs will be encouraged, in particular, to explore options for 'Action' that

link mothers and households with PSNP programme, agricultural extension programme of the

Woreda and Concern's livelihoods project, to improve access to a more diversified and quality

diet, where that is a key barrier to optimum IYCF.

Activities planned to be implemented at community level include counselling, supporting

households to diversify production through integrating nutrition into business plans and

following up implementation, and increasing utilisation of health services by the beneficiaries.

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SESSION TWO: ADDRESSING MALNUTRITION IN THE CONTEXT OF

PSNP

Learning objectives

By the end of the session, participants will be able to:

List causes of malnutrition.

Explain how optimal IYCF can be related to PSNP to reduce malnutrition.

Describe the malnutrition situation in the Woreda.

Identify prevailing IYCF and maternal feeding practices in the community.

Activity overview

Activity 2.1 Presentation of conceptual framework of malnutrition. (30 minutes)

Activity 2.2 Discuss how optimal IYCF is related to PSNP. (15 minutes)

Activity 2.3 Discussion of malnutrition situation in the Woreda. (30 minutes)

Activity 2.4: Identify prevailing IYCF and maternal feeding practices. (30 minutes)

Total Time: 105 minutes

Materials needed

Cards (½ A4 size) and cards with headings: Basic, Underlying, Immediate, and Consequences.

Pictures of people/community working during PSNP, sick child with diarrhoea, respiratory

infection, malnutrition and fever.

Flipchart with: situation of IYCF and PSNP in Dessie Zuria Woreda.

Advance preparation

Teaching aids: pictures of community working during PSNP, child with diarrhoea, respiratory

infection, malnutrition and fever.

Hand outs

HO 2A: Summary of Dessie Zuria IYCF baseline survey findings.

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Activity 2.1: What are the different causes of malnutrition? (30 minutes)

In groups of 3, participants write on cards - 3 different causes of malnutrition (one cause per card)

Groups tape cards on wall, overlapping similar causes.

Facilitator helps to group or cluster causes:

- Basic: (political, economical, cultural)

- Underlying: (food security, women care, child care, health, environment)

- Immediate: (food intake, Illness)

Facilitators ask participants: how are the causes of malnutrition related to PSNP?

Facilitator asks participants: what are the consequences of malnutrition? [Examples: reduced

productivity, reduced educational levels leads to under development)

Discussion and summary.

Activity 2.2: Discuss how optimal IYCF is related to PSNP (15 minutes)

Brainstorm answers to the question: do you think PSNP has an effect on the nutritional status of

beneficiaries (including pregnant and lactating mothers)? If yes how? If not, what do you think can

be done for better effect?

Place on flipchart or wall pictures of community working on PSNP and relate to IYCF.

Put the word IYCF at the centre of a flipchart, and ask participants to brainstorm on how IYCF relates

to the PSNP interventions: growth and development, CF, gardening, household food security.

Summarise: PSNP works mainly on rehabilitating the degraded environment so that it will regain

better productivity. PSNP can help to develop the human brain by working on nutrition especially on

children under two years.

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Activity 2.3: Discussion on malnutrition situation in the Woreda (30 minutes)

Divide participants into 6 small groups and assign each group one question to discuss.

1. What do you think are the most important causes of malnutrition in Dessie Zuria?

2. Why do you think malnutrition in the Woreda is chronic despite many years’ (decades)

presence of partners and various programme interventions?

3. Discuss the possible best combined options that would help alleviate malnutrition in the

Woreda?

4. What are the achievements of interventions to improve malnutrition situation in the Woreda?

5. What are the current challenges and missed opportunities of interventions against malnutrition

in the Woreda?

6. List both governmental and nongovernmental partners working on malnutrition. How do you

describe the level and efficiency of partnership and coordination among partners and

stakeholders working on malnutrition (mainly IYCF) and food security (mainly PSNP)? What can

be done to improve the problems?

Allow 5 to 10 minutes for discussion. Each group should select a secretary and a presenter

before the discussion. (Provide a marker and flipcharts to each group)

After group discussion invite each group to present their findings. (5 to 10 minutes)

At the end of the presentations, in plenary ask and discuss if there are unclear issues. Thank

the presenters and group members for their participation.

Summarise the session, listing on a flip chart the most important issues raised during

discussions. (5 minutes)

Refer to findings on IYCF practices from Dessie Zuria IYCF baseline survey

Before concluding, ask participants: where are the gaps from the summary data? Do you

think those gaps can be addressed only by the roles of HEWs/VCHWS? Who should be

involved to address those gaps?

Emphasise exclusive breast feeding, minimum dietary diversity, minimum acceptable diet

and consumption of iron-rich foods.


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HO 2A: Findings of recent assessment conducted at Dessie Zuria Woreda:

Indicator Description N n %

I. Infant and young child

1. Initiation of Breast

feeding

Proportion of children born in the last 24

months who were put to the breast within

one hour of birth

675 174 25.8

2. Exclusive breast

feeding under 6

months

Proportion of infants 0 – 5 months of age

who are fed exclusively with breast milk

201 71 35.3

3. Continued breast

feeding at 1 year

Proportion of children 12 – 15 months who

are fed breast milk

130 129 99.2

4. Introduction of solid,

semi-sold, soft food

Proportion of infants 6 – 8 months who

receive solid, semi solid or soft foods

78 50 64.1

5. Minimum dietary

diversity


receive foods from 4 or more food groups

492 64 13.0

6. Minimum meal

frequency

Proportion of breastfed and non-breastfed

children 6 – 23 months who receive solid,

semi-solid, or soft foods the minimum

number of times or more

492 285 57.9

7. Minimum acceptable

diet


receive a minimum acceptable diet (apart

from breast milk) – composite of dietary

diversity and meal frequency

492 46 9.3

8. Consumption of iron-

rich foods


receive an iron-rich food or iron-fortified

food that is specially designed for infants

and young children, or that is fortified in the

home

492 19 3.9

9. Children ever

breastfed

Proportion of children born in the last 24

months who were ever breastfed

675 675 100

10. Continued breast

feeding at 2 years


are fed breast milk

84 76 90.5

11. Age-appropriate

breastfeeding


are appropriately breastfed

693 495 71.4

II. Maternal

Maternal post-partum

vitamin-A

Proportion of women with live birth in the

last 24 months who received high dose

679 70 10.3

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supplementation vitamin A supplementation within 8 weeks

of delivery

Provision of de-worming

tablets for pregnant

women


last 24 months who took de-worming

medication during pregnancy

679 24 3.5

Iron supplementation for

pregnant women during

pregnancy


last 24 months who consumed iron tablets

during the last pregnancy

No 547 80.6

<60 days 123 18.1

60-89 days 8 1.2

90 + days 1 0.1

Total 679 100

Activity 2.4: Identify prevailing IYCF and maternal feeding practices (30 minutes)

Divide participants into 3-5 small groups.

Ask groups to discuss existing IYCF and maternal feeding practices in their locality (allow 10

minutes for discussion).

Facilitator asks participants to write a list of current breast feeding practices in their community

on cards provided.

Facilitators post on the wall three classifications of breast feeding practice as helpful, harmful

and don’t know.

Facilitators ask the participants to tape on the wall the breastfeeding practices they discussed,

based on the classification.

Groups tape cards on wall, overlapping similar classification of breast feeding practices.

Facilitator helps to group or cluster causes.

Discussion, feedback and summary.

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SESSION THREE: OVERVIEW OF IYCF AND PSNP PROGRAMMES

Objectives: At the end of this session the participants will be able to:

Describe the national IYCF strategies.

Describe PSNP within Food Security Programme (FSP).

Activity overview

Activity 3.1: Overview of IYCF in Ethiopia. (90 minutes)

Activity 3.2: Overview of PSNP in Ethiopia. (60 minutes)

Total time: 150 minutes

Materials needed

Flip chart stand

Flipchart paper, marker

Masking tape

Blank cards

Handouts

Advance preparation

Prepare and review flip chart presentation.

Read and rehearse each step of the activity.

Make enough copies of participants’ handouts.

Prepare group exercises.

Hand outs

HO 3A: overview of IYCF programme in Ethiopia.

HO 3B: overview of FSP and PSNP in Ethiopia.

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Activity 3.1: Overview of IYCF in Ethiopia (90 minutes)

Brainstorm the following questions and conduct discussions:

1. What do you know about IYCF programme in Ethiopia?

2. What are the nutritional interventions included in the national IYCF strategy?

3. What are the entry points for IYCF interventions in PSNP?

Summary of the discussions using points from HO 3A. Emphasise entry points in PSNP.

HO 3A: Overview of IYCF programme in Ethiopia

Ethiopian IYCF strategy has been prepared based on the national needs and commitments to

improve IYCF practices and follows the WHO Global Strategy for Infant and Young Child

Feeding.

The Essential Nutrition Actions (ENA) or action-oriented approach focuses on promoting seven

clusters of intervention that are proven to reduce morbidity and mortality are included in the

IYCF strategy.

The main beneficiaries of these actions will be infants and young children under the age of two

years as well as women of reproductive age. The seven ENA areas include:

1. Promoting optimal breastfeeding.

2. Promoting optimal complementary feeding at 6 months.

3. Nutritional care of the sick child during and after illness.

4. Improving women’s nutrition.

5. Controlling anaemia.

6. Controlling vitamin A deficiency.

7. Controlling iodine deficiency.

What are the entry points to promote ENA?

1. Pregnancy.

2. Delivery/immediate postpartum.

3. Postnatal/ family planning.

4. Immunisation.

5. Growth monitoring/well child.

6. Sick child consultations.

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Activity 3.2: Overview of PSNP in Ethiopia (60 minutes)

Brainstorm the following questions and conduct discussions:

1. What do you know about the Food Security Programme in Ethiopia?

2. What do you know about the PSNP in Ethiopia?

3. What are the nutritional and food security interventions included in the national PSNP strategy?

4. What are the possible entry points to promote IYCF interventions in PSNP?

Summary of the discussions using HO 3B

Handout 3B: Overview of PSNP in Ethiopia

FSP and PSNP

The PSNP lies within the Government of Ethiopia’s Food Security programme (FSP) which is a key

pillar of Ethiopia’s Food Security Strategy. The PSNP is one of four components of the FSP. Other

components are the:

1. Household Asset Building (HABP)

2. Complementary Community Infrastructure (CCI)

3. Resettlement

What is PSNP?

In 2003, building on its National Food Security Strategy, the Government launched a major

consultation process with development partners that aimed to formulate an alternative to crisis

response to support the needs of chronically food insecure households, as well as to develop long-

term solutions to the problem of food insecurity.

Under the FSP, in 2005 the Government started a major new initiative - the Productive Safety Net

(PSNP).

Chronic food insecurity

Transitory food insecurity

Objective of PSNP

To assure food consumption and prevent asset depletion for food insecure households in chronically

food insecure Woredas, while stimulating markets, improving access to services and natural

resources, and rehabilitating and enhancing the natural environment.

Principles of PSNP

To ensure that the PSNP is effective in achieving its objectives it needs to be implemented with certain

principles. These are:

1. Fair and transparent client selection.

2. Timely, predictable and appropriate transfers.

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3. Primacy of transfers.

4. Productive nature of the programme.

5. Integrated into local systems.

6. Scalable safety nets.

7. Cash first principle.

8. Gender equity.

Elements of PSNP

The PSNP has 5 main elements that combine to achieve the PSNP objectives. These are listed as

follows:

1. Transfers for chronically food insecure households: transfers may be in cash or food. PSNP clients

qualify for transfers in two ways:

a. Conditional transfers

b. Unconditional transfers

2. Transfers for households affected by shocks.

3. Public Works to create sustainable infrastructure.

4. Capacity building for effective PSNP delivery.

5. Coordination between implementers and with other development and relief efforts.

Who are the beneficiaries of PSNP?

The beneficiaries of the PSNP are the food insecure populations living in chronically food insecure

Woredas.

Types of beneficiaries: public work and direct support.

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SESSION FOUR: OPTIMAL BREASTFEEDING PRACTICES

Learning objectives


Explain the benefits of breastfeeding.

Explain the optimal breastfeeding practices and importance of each practice.

Explain Food Security Task Force (FSTF) member roles in promoting optimal breastfeeding

practices.

Activity overview

Activity 4.1 Discuss the benefits of breast feeding. (60 minutes)

Activity 4.2 Explain the optimal breastfeeding practices. (60 minutes).

Activity 4.3 Discuss how FSTF members can support optimal breastfeeding practices. (90

minutes)


Materials needed

Flipchart papers (+ markers + masking tape)

Large cards (½ A4 size)

Dolls and/or babies

Breast models

Advance preparation


Read and rehearse each step of the activity.


Prepare dolls and breast model materials for proper positioning and attachment demonstration.


Hand outs

HO 4A: Benefits of breast feeding.

HO 4B: Key messages on optimal breastfeeding 0 – 6 months.

HO 4C: Position and attachment techniques.

25

Note: If possible, make arrangements in advance to have breastfeeding women present, but be

sure to obtain informed consent.


Activity 4.1: Discuss the benefits of breastfeeding (60 minutes)

Divide participants into 4 groups. Four flipcharts are set-up throughout the room with the following

titles: benefits of breastfeeding for the infant, benefits of breastfeeding for the mother, benefits of

breastfeeding for the family, and benefits of breastfeeding for the community/nation.

Each group has 3 minutes at each flipchart to write as many benefits as they can think of (without

repeating benefits already listed), then the groups rotate to the next flipchart and repeat the

exercise.

Discussion and summary in plenary. Refer to HO 4A and discuss.

HO 4A: Benefits of breastfeeding

BENEFITS OF BREASTFEEDING FOR THE INFANT/YOUNG CHILD

Saves infants’ lives.

Is a whole food for the infant, contains balanced proportions and sufficient quantity of all

the needed nutrients for the first 6 months.

Promotes adequate growth and development, thus preventing stunting.

Is always clean.

Contains antibodies that protect against diseases, especially against diarrhoea and

respiratory infections.

Is always ready and at the right temperature.

Is easy to digest. Nutrients are well absorbed.

Protects against allergies. Breast milk antibodies protect the baby’s gut preventing harmful

substances from passing into the blood.

Contains enough water for the baby’s needs (87% of water and minerals).

Helps jaw and teeth development; suckling develops facial muscles.

Frequent skin-to-skin contact between mother and infant leads to better motor skills, and

affective and social development of the infant.

The infant benefits from the colostrum, which protects him/her from diseases. The

colostrum acts as a laxative cleaning the infant’s stomach.

BENEFITS OF BREASTFEEDING FOR THE MOTHER

Breastfeeding is more than 98% effective as a contraceptive method during the first 6 months

26

provided that breastfeeding is exclusive and amenorrhea persists.

Putting the baby to the breast immediately after birth facilitates the expulsion of placenta

because the baby’s suckling stimulates uterine contractions.

Reduces risks of bleeding after delivery.

When the baby is immediately breastfed after birth, breast milk production is stimulated.

Immediate and frequent suckling prevents engorgement.

Reduces the mother’s workload (no time is involved in boiling water, gathering fuel, or

preparing milk).

Breast milk is available at anytime and anywhere, is always clean, nutritious and at the right

temperature.

It is economical.

Stimulates bond between mother and baby.

Reduces risks of pre-menopausal breast and ovarian cancer.

BENEFITS OF BREASTFEEDING FOR THE FAMILY

No expenses in buying formula, firewood or other fuel to boil water, milk or utensils. The

money saved can be used to meet the family’s other needs.

No medical expenses due to sickness that formula could cause. The mothers and their

children are healthier.

As illness episodes are reduced in number; the family encounters few emotional difficulties

associated with the baby’s illness.

Births are spaced thanks to the contraceptive effect.

Time is saved.

Feeding the baby reduces work because the milk is always available and ready.

FOR THE COMMUNITY/NATION

Not importing formula and utensils necessary for its preparation saves money that could be

used for something else.

Healthy babies make a healthy nation.

Savings are made in health spending. A decrease in the number of child illnesses leads to

decreased national expenditure on treatments.

Improves child survival. Reduces child morbidity and mortality.

Protects the environment (trees are not used for firewood to boil water, milk and utensils,

thus protecting the environment). Breast milk is a natural renewable resource.

27

Activity 4.2: Explain the optimal breastfeeding practices (60 minutes)

Divide participants into five groups, giving each participant one card.

Each participant will write one optimal breastfeeding practice on their card.

Small groups share, discuss and make a list of optimal breastfeeding messages.

Each group tapes their breastfeeding messages on the wall.

Distribute HO 4B on optimal breastfeeding messages. Ask participants to read one message at a

time and discuss.

Demonstrate proper positioning and attachment (refer HO 4C).

HO 4B: Key messages for Ethiopia on optimal breastfeeding 0 to 6 months

1. Mother Give the first yellow milk made especially for the new born as it will protect your baby from illness.

Supporting information

This first yellow milk (colostrum) is the mother’s natural butter and will help to expel your baby’s first dark stool.

Colostrum contains many important factors which will protect your new baby from disease.

2. Mother Put your baby on the breast immediately after birth, even before the placenta is expelled, to stimulate your production of milk.


Immediate breastfeeding within one hour of birth will help to expel the placenta and reduce post-partum bleeding.

Pre-lacteal feeds (such as sugar water, water, butter, ersho) are not necessary and may interfere with establishing good breastfeeding practices during the first days of the baby’s life.

3. Mother Feed your baby only breast milk for the first six months, not even giving water, for it to grow healthy and strong.


Feeding the baby only breast milk provides the best nourishment possible for the baby and will protect it from diseases such as diarrheoa and respiratory infections.

Giving the baby water or other liquids may make your baby sick with diarrheoa.

If the baby takes water or other liquids, its appetite for breast milk may decrease meaning it sucks less on the breast leading to poor growth.

Even during very hot weather, breast milk will satisfy your baby’s thirst for liquids during the first six months.

4. Mother Breastfeed your baby on demand, at least 10 times day and night, to produce

28

enough milk and provide your baby enough food to grow healthy.


Frequent breastfeeding helps the milk to flow.

Increases bonding between mother and child.

Ensure proper positioning and attachment so baby gets adequate breastmilk and to avoid breast problems such as sore and cracked nipples.

Advise mothers with nipple and breast problems to seek immediate care from Health Worker (HW).

5. Mother Empty one breast first before switching to the second for your baby to get the most nutritious hind milk to grow strong and healthy.


Foremilk quenches thirst because it is more watery.

Hind milk is richer and satisfies the baby’s hunger so that it will not cry as much.

6. Father Ensure that your wife who is breastfeeding has two extra meals a day to maintain her health and the health of the baby.


To maintain their health breastfeeding women need to eat a wide variety of foods, particularly animal products (meat, milk, eggs, etc), fruits and vegetables.

Ripe papaya, orange, carrot, pumpkin and mango are especially good for the mother.

7. Mother During illness, increase the frequency of breastfeeding for your baby to recover faster.


Continue to breastfeed during diarrheoa, even increasing the frequency, to replace the liquid lost.

Breastfeeding more during illness will help your baby to fight sickness and not lose weight.

Breastfeeding also provides comfort to a sick baby.

Sick mothers can continue to breastfeed their baby.

8. Mother After each illness increase the frequency of breastfeeding for the baby to regain health and weight.


Each time a baby is sick, it will lose weight so it is important to breastfeed as often as possible.

Your breast milk is the safest and most important food you can offer your baby to regain its health and weight.

9. Mother Take vitamin A supplementation within 45 days of delivery for the baby’s health and strength.


Ask a HW for vitamin A supplementation after the birth of the baby.

Taking a vitamin A capsule will enrich the mother’s breastmilk with important nutrients to keep the baby healthy and strong.

10. All family members

Sleep under an insecticide treated net (ITN), especially pregnant women and children, to prevent getting malaria.

29


Malaria causes anaemia which will make members of your family unwell and very tired.

Family members with fever need to be taken to a health facility for immediate treatment.

Additional nutrition message for infants 0 to 6 months on vitamin D

11. Mother and father

Expose your baby to sunlight for 20 to 30 minutes daily to ensure it grows well


Exposure to sunshine will help ensure your baby has adequate vitamin D which is important for bone growth and good health.

HO 4C: Position and attachment techniques

1. Preparation and how to breastfeed (proper positioning)

The mother must be comfortable.

Hold the infant in such a way as to have his/her face at the mother’s breast level .The infant

should be able to look up at the mother’s face, not flat to her chest or abdomen.

The infant’s stomach should be against the mother’s stomach.

The infant’s head, back, and buttocks are in a straight line.

The infant needs to be close to the mother.

The infant is brought to the breast; the baby's whole body should be supported, not just the

head and shoulders.

The mother should hold her breast with her fingers in a C-shape, the thumb being above the

areola and the other fingers below. Fingers should not be in a scissor-hold because this method

tends to put pressure on the milk ducts and can take the nipple out of the infant’s mouth.

2. Signs of proper attachment

Good attachment is important to enable the infant to suckle

effectively, to remove the milk efficiently, and stimulate an adequate

supply.

Poor attachment results in incomplete removal of milk, which can lead

to sore nipples, inflammation of the breast and mastitis.

Tease the infant’s lower lip with the nipple, in order for the infant to open wide his/her mouth.

The infant’s mouth should cover a large part of the areola (there is more areola showing above

rather than below the nipple).

The areola and the nipple will stretch and become longer in the infant’s mouth.

The infant’s chin touches the breast.

Both lips are turned outwards.

3. Signs of efficient suckling

Slow and regular sucking at the following rhythm: 2 suctions and one swallowing.

30

The infant takes slow deep sucks, sometimes pausing.

Suckling is comfortable and pain free.

The mother hears her baby swallowing.

The breast is softer after the feed.

Demonstration of different breastfeeding positions

1. Sitting position

Usual position of Ethiopian mothers

Make sure infant’s and mother’s stomachs are facing each

other

2. Side-lying

This position is more comfortable for the mother

after delivery and it helps her to rest while

breastfeeding.

The mother and infant are both lying on their side

and facing each other.

3. American Football

This position is best used:

- after a Caesarean section,

- when the nipples are painful, or

- to breastfeed twins.

The mother is comfortably seated with the infant under her

arm. The infant’s body passes by the mother’s side and his/her

head is at breast level.

The mother supports the infant’s head and body with her hand

and forearm.

Ask one or two participants to demonstrate this position with a doll and a breast model.

Regardless of the position chosen, the mother must be comfortable. She should not lean toward the

infant but rather draw him/her towards herself. For example, sitting position: back resting on the chair’s

back or cushion, feet crossed or raised on a stool.

Activity 4.3 How FSTF can support promotion of optimal breastfeeding practices (90 minutes)

Divide participants into 5 groups; each group answers one of the following questions:

1. How can a FSTF and VCHW help mothers or caretakers achieve optimal breastfeeding

practices?

2. How can optimal breastfeeding practices be promoted during the PSNP activities?

Presentations by the groups

Discussion and summary in plenary

31

Facilitator’s note

Possible answers:

Question 1: How can a FSTF and VCHW help mothers or caretakers achieve optimal breast feeding?

Discuss the benefits of breastfeeding and birth spacing with the mother, her husband and family

(if possible).

Help the mother to breastfeed immediately after delivery at hospital, at home, or at the

midwife’s, and to give colostrum to the baby because colostrum:

- Protects infant from disease by providing the infant’s first vaccine.

- Helps expel the placenta more rapidly and reduce blood loss.

- Helps expel meconium, the infant’s first stool.

- Stimulates breast milk production.

- Keeps newborn warm through skin-to-skin contact.

Promote exclusive breastfeeding from 0 - < 6 months because:

- Breast milk contains all the water and nutrients that an infant needs to satisfy hunger and

thirst.

- Infants are likely to have fewer diarrheoa, respiratory, and ear infections.

- Exclusive breastfeeding helps space births by delaying the return of fertility.

Also

Answer mother or caregiver’s questions.

Congratulate and encourage the mother/caregiver.

Encourage mother/caregiver to go to a community support group if she encounters

breastfeeding difficulties.

Refer her to community support groups or the health facility for other FP methods.

Remind mother or caregiver to immunise the child: BCG, DPT, and Polio.

Question 2: How can optimal breastfeeding practices be promoted during the PSNP activities?

During the monthly cash payment and through group counselling.

During the working day HEWs can provide advice about optimal breast feeding practices.

32

SESSION FIVE: OPTIMAL COMPLEMENTARY FEEDING PRACTICES AND

COOKING DEMONSTRATION

Learning objectives


Explain the importance of complementary feeding (CF).

Describe key behaviour pertaining to child feeding from 6 to 24 months.

Advise mothers and negotiate with other family and community members to adapt desired CF

behaviours.

Develop skills on preparation of CF recipes.

Describe the role of fathers on complimentery feeding preparation

Identify the roles of different Food Security Task Force (FSTF) members in improving desired CF

practices

Activity overview

Activity 5.1 Explain key CF behaviours from 6 – 24 months and presentation of FATVAH.

(90 minutes)

Activity 5.2 Seasonally available foods calendar. (60 minutes)

Activity 5.3 Preparation of CF recipe and describe fathers role. (120 minutes)

Activity 5.4 Roles of FSTF to improve key CF practices from 6 – 24 months. (60 minutes)


Materials needed

Flipchart papers (+ markers + masking tape).

Foods items purchased at local market, and utensils, for CF recipe preparation.

Advance preparation


Read and rehearse each steps of the activity.


Prepare food items and utensils for preparation of CF.


33

Hand outs

HO 5A: Recommended CF practices.

HO 5B: Key messages for Ethiopia on CF with BF 6 to 24 months.

HO 5C: Active feeding.

HO 5D: Calendar: inexpensive and available foods (market and/or home).

HO 5E: Quality of CF.


Activity 5.1: Explain key CF behaviours from 6 – 24 months and presentation of FATVAH (90 minutes)

Ask participants: at what time (age) families in their community start to give complementary foods,

and why families in the communities start at the indicated age?

Brainstorm with participants the question: what are the characteristics of CF?

- Probe until the following characteristics are mentioned: Frequency, Amount, Texture

(thickness/consistency), Variety (different foods), Active or responsive feeding, and Hygiene

(FATVAH)

Group Work

Prepare a flipchart with columns: age, frequency, amount, and texture, and rows: 6 – 8 months 9 –

11 months, and 12 – 23 months.

Divide participants in to four groups, each group works on the recommended CF practices and

completes the table.

Presentation by the group.

Facilitator sumamrises with a presentation on the recommended complementary feeding practices

(HO 5A).

Participants read HO 5B on key messages on CF with BF 6 to 24 months for Ethiopia. Ask

participants to explain each message and sumamrise.

Participants read messages on active feeding (HO 5C); discuss and sumamrise.

34

Flipchart: Recommended complementary feeding practices

Age Frequency (Per Day) Amount of food an

average child eat at each

serving

Texture (thickness

/consistency)

Variety

6-8

months

9-11

months

12-23

months

HO 5A: Recommended complementary feeding practices

Age Frequency (Per

Day)

Amount of food an

average child eat at

each serving

Texture (thickness

/consistency)

Variety

6-8

months

3 times (gradual

introduction of 1-

2 tablespoons in

first few days

after 6 months,

and gradually

increase the

amount)

1 full coffee cup

+

+

1-2 snacks

Soft, thick porridge,

mashed vegetables, finely

chopped meat and fruit

Breast feeding

+ staples

(porridge)

legumes,

vegetables,

fruits, and

animal

products

including egg

9-11

months

4 times 1 full coffee cup

+

1-2 snacks

Soft, more thick than the

previous months; family

foods, chopped or

mashed if necessary;

enriched porridge

12-23

months

4 times 1-1 ½ full coffee cup

+

1-2 snacks

Responsive Active Feeding Be patient and actively encourage your baby to eat.

Hygiene Feed your baby using a clean cup and spoon, never a bottle as this is difficult to

clean and may cause your baby to get diarrheoa.

Wash your hands with soap and water before preparing food, before eating, and

before feeding young children to avoid diarrheoa.

35

HO 5B: Key messages for Ethiopia on CF with BF 6 to 24 months

1. Mother

and father

Introduce complementary foods at six months of age, such as soft porridge 2-3

times a day, for your baby to grow healthy and strong.

Supporting

information

- Porridge can be made from many different types of cereals and tubers (e.g.

potatoes).

- The consistency of the porridge should be thick enough to be fed by hand.

- Thicken the porridge as the baby grows older, making sure that it is still able to

easily swallow without choking.

- Thin gruels made with water are not healthy for your baby as they do not

provide enough of the nutrients it needs to grow strong and healthy.

- When possible use milk instead of water to prepare the porridge.

- Foods given to the child must be stored in hygienic conditions to avoid

diarrheoa and illness.

- First types of complementary foods, such as porridges, found in different

regions that can be used to feed babies 6 to 12 months of age include (in Dessie

Zuria):

- genfo prepared from barley

2. Mother Continue to breastfeed your child on demand, at least 8 times, day and night until

two years and beyond to maintain its strength.

Supporting

information

- During the first and second year, breast milk is still an important source of

nutrients for your baby.

3. Mother

and father

Enrich your baby’s porridge with 2 to 3 different types of foods at each meal (such

as butter, oil, peanuts, meat, eggs, lentils, vegetables and fruits) for it to grow and

get strong.

Supporting

information - From 6 months onwards, feed your child 2-3 types of different enrichment foods

with the porridge at each meal, in addition to breast milk.

- Try to feed different foods each time.

- Mash and soften the enrichment foods so the baby can easily chew and swallow

without choking.

- Cow’s milk can be offered to your child in addition to the enrichment foods

given, (but not as a replacement to the the enrichment foods).

- Add butter and oil every time.

- Animal foods (meat, liver, fish and eggs) are especially good for your baby and

will keep it healthy and strong.

- Ripe orange/yellow fruits (papaya, mangos) and vegetables (carrots) are good

sources of vitamin A.

36

- Dark green leaves (kale, chard, shiferaw) and legumes contain important

nutrients such as iron and will help your baby grow strong.

Types of enrichment foods that can be given with the porridge include:

Oil and butter

Meat and fish

Eggs

Peanuts, beans, peas or lentils

Ripe papaya or mangoes

Carrots

Avocados

Dark green leafy vegetables

4. Mother

and father

From 6 to 12 months of age, in addition to the 2-3 servings of enriched porridge,

also feed your baby 1-2 other solid foods (mekses) each day to ensure healthy

growth.

Supporting

information

- Babies have small stomachs and can only eat small amounts at each meal so it

important to feed them frequently throughout the day.

- By 8 months the baby should be able to begin eating finger foods such as pieces

of ripe mango & papaya, avocado, banana, other fruits & vegetables, fresh &

fried bread products, boiled potato, sweet potato, kita (unleavened bread), etc.

- Feed these finger foods as snacks (mekses) at least 1-2 times each day.

- Foods given to the child must be stored in hygienic conditions to avoid diarrheoa

and illness.

5. Mother

and father

From 12 to 24 months of age, feed your child at least 3-4 times a day using family

foods, along with 1-2 other solid foods (mekses) each day to ensure healthy

growth.

Supporting

information - It is very important that the family’s meals are also enriched with a variety of

foods and that the child eats a variety of foods.

- Young children have small stomachs and can only eat small amounts at each

meal so it important to feed them frequently throughout the day.

- Other solid foods (mekses) can be given as many times as possible each day and

can include ripe mango & papaya, avocado, banana, other fruits & vegetables,

fresh & fried bread products, boiled potato, sweet potato, kita (unleavened

bread), etc.


and illness.

37

6. Mother

and father

As your baby grows older, increase the amount of food at each meal in order to

ensure that they are eating enough to maintain healthy growth.

Supporting

information

The following are examples of different foods and the amounts that can be fed to

infants and young children. Change these recipes each day using a variety of

different foods remembering to encourage your child to eat more at each meal as

they get older:

Each day a 6 to 8 months old baby can eat:

- 2 full ‘buna’ cups of cooked soft sorghum porridge enriched with 1 teaspoon oil

and 1 teaspoon of pea flour (shiro) [If two meals are fed to baby each day, feed

1 ‘buna’ cup of enriched porridge at each meal] and

- 1 full ‘buna’ cup of milk (either given to baby in a cup or used to cook porridge

instead of water) and

- 3 teaspoons of mashed ripe mango as mekses and

- juice of one small orange as mekses and

- iodized salt to cook enriched porridge

Each day a 9 to 11 month old baby can eat:

- 3 full ‘buna’ cups of cooked enset porridge enriched with 2 teaspoons oil, 3

leaves of kale, 1 teaspoon of pea flour (shiro) and 1 egg [If three meals are fed

to the baby each day, feed 1 ‘buna’ cup of enriched porridge at each meal] and

- 1 full ‘buna’ cup of milk (either given to baby in a cup or used to cook porridge


- 1/2 mashed ripe mango as mekses and

- 1 piece of cooked sweet potato as mekses and

- iodized salt to cook enriched porridge

Each day a 12 to 24 month old child can eat:

- 4 full ‘buna’ cups of fitfit made with: 1/3 injera circle, 2 teaspoons oil, 1

tablespoon pea flour (shiro), 1 small onion, 1 potato and 3 leaves of kale. [Feed

child this amount over 3-4 meals during the day] and

- 2 big ‘buna’ cups of milk (either given to baby in a cup or sed to cook fit fit


- mashed papaya as mekses and

- 1 avocado as mekses and

- iodized salt to cook the fitfit

38

7. Mother Be patient and actively encourage your baby to eat all its food in order to grow

healthy.

Supporting

information

- At first the baby may need time to get used to eating foods other than

breastmilk so have patience and take enough time to feed them, even using play

to help them eat. Make the time for eating special.

- Use a separate plate to feed the child to make sure it eats all the food given.

- Force-feeding will discourage babies and young children from eating.

- As they are too little to feed themselves, babies need to be fed directly to make

sure they eat all the food given to them.

- Even when older, young children should be supervised during mealtime to make

sure they eat all the food put on their plate.

8. Mother

and father

During illness, increase the frequency of breastfeeding and offer additional food to

your child to help it recover faster.

Supporting

information

- Fluid and food requirements are higher during illness.

- Take time to patiently encourage your sick child to eat as their appetite may be

decreased because of the illness.

- It is easier for a sick child to eat small frequent meals so feed the child foods it

likes in small quantities throughout the day.

- It is important to keep breastfeeding and feeding complementary foods to your

child during illness to maintain its strength and reduce the weight loss.

9. Mother

and father

When your child has recovered from an illness, give it one additional meal of solid

food each day during the two weeks that follow to help it recover quickly.

Supporting

information

- Children who have been sick need extra food and should be breastfed more

frequently to regain the strength and weight lost during the illness.

- Take enough time to actively encourage your child to eat this extra food as they

still may not appear hungry due to the illness.

10. Mother

and father

Feed your baby using a clean cup and spoon, never a bottle as this may cause your

baby to get diarrheoa.

Supporting

information

- Nutritious porridges for children should be thick enough to be fed by hand.

Porridge that is too watery and can be fed with a bottle will not help your baby

to grow.

- Bottles are very difficult to keep clean and can make your baby sick with

diarrheoa.

- Cups can be used to feed your baby, are easy to keep clean and are cheaper to

buy than a bottle.

39

11. Mother

and family

Wash your hands with soap and water before preparing food, before eating, and

before feeding young children to avoid diarrheoa.

Supporting

information

- Touching food with unclean hands can cause diarrheoa.

- Utensils for feeding the baby also have to be clean.

- Use a cup to feed a baby or a young child never a bottle which can cause

diarrheoa.


and illness.

12. Mother

and father

When your baby is 6 months old, make sure it receives vitamin A supplementation

every six months to make it strong.

Supporting

information

- Ask a HW to give vitamin A supplementation two times a year to your child

between 6 to 59 months of age.

- Vitamin A is important for your child’s eyesight as well as helping your child fight

illness.

- Be sure to bring your child to vitamin A supplementation sessions during child

health days.

13.Mother

and father

Find ripe orange/yellow fruits and vegetables or liver to feed your child to keep it

healthy.

Supporting

information

- These foods are good sources of vitamin A and other nutrients that will help your

child grow strong and healthy.

- Children should eat these foods as often as possible.

14.Mother

and father

When your child is two years old, it has to receive de-worming medicine every six

months to maintain healthy growth.

Supporting

information

- Ask a HW for de-worming medicine to be given two times a year to your child

between the ages of 2 to 5 years.

- Intestinal parasites cause young children to become anemic which will make

your child unwell and tired.

15.All

family

Sleep under an insecticide treated net (ITN), especially pregnant women and

children, to prevent getting sick with malaria.

Supporting

information

- Malaria causes anaemia which will make members of your family unwell and

very tired.

- Family members with fever need to be taken to a health facility for immediate

treatment.

16. Mother

and father

Ensure that all family food is cooked using iodized salt so that family members

remain healthy.

Supporting - Iodized salt is not available everywhere, but should be used when available.

40

information - Pregnant women need to use iodized salt to ensure the health of their new baby.

Additional nutrition message for children 6 to 12 months on vitamin D

17. Mother

and father

Expose your child to sunlight for 20 to 30 minutes daily to ensure it grows well

Supporting

information

- Exposure to sunshine will help ensure your child has adequate vitamin D which is

important for bone growth and good health.

HO 5C: Active feeding

HOW DO MOTHERS/CAREGIVERS ACTIVELY FEED

Definition: Active/responsive feeding is a method that encourages the child to eat and to finish

his/her meals.

Importance of active feeding:

When feeding him/herself, a child may not eat enough. He/she is easily distracted. Therefore

he/she needs help. When a child does not eat enough, he/she will become malnourished.

Let the child eat from his/her own plate (caregiver then knows how

much the child is eating).

Sit down with the child and encourage him/her if needed.

Offer food the child can take and hold; the young child often wants to

feed him/herself. Encourage him/her to, but make sure most of the

food goes into his/her mouth.

Mother/caregiver can use her fingers (after washing) to feed child.

Feed the child as soon as he/she starts to get hungry.

The child should eat in his/her usual setting.

As much as possible, the child should eat with the family in

order to create an atmosphere promoting his/her

psychological development.

Do not insist if the child does not want to eat.

If the child refuses to eat, wait or put it off until later.

Play with the child while he/she eats.

Make sure the child is not thirsty (but do not give him/her too

much drink before or during meals).

Congratulate the child when he/she eats.

Parents, family members (older children), child caretakers can

participate in active feeding.

41

Activity 5.2: Seasonally available foods calendar (60 minutes)

Refer to Handout 5D: seasonal food availability calendar.

Participants should group themselves according to the area they work.

Each group will fill the calendar with foods available during the given season.

2 groups present the results.

Discuss if the foods identified are adequate.

Participants are then asked to finish filling the calendar once they get back to their own

village/Kebele.

If you don’t find important food items, exchange it with what ever you do have e.g. barley for

carrot, barley for for flax seed or vegetables.

Facilitator presents on the the quality of complementary food (HO 5E).

42

HO 5D: Seasonal food availability calendar: inexpensive and available foods (market and/or home) (To

be filled every month and brought to each training and follow-up)

January February March

Home

Home Home

Market

Market

Market

April May June

Home

Home Home

Market

Market Market

July August September

Home

Home Home

Market

Market Market

October November December

Home

Home Home

Market

Market

Market

43

HO 5E: Quality of Complementary Foods

Some types of foods that could be mixed with staple foods to help children grow well and strong:

No. Food group Use Question for discussion Source

(Production/

Purchase)

1 Pulses: peas, beans,

lentils and nuts ( good

sources of protein).

Important for

growth and

repair, body

building.

Pulses are produced in a very

small amount in the

intervention Kebeles. Is there

a way that the production can

be increased?

2 Animal source food : red

flesh meat, organs such

as liver and heart, milk,

yogurt, cheese and eggs,

(good sources of iron and

zinc).

Will assist in

growth and

development and

will help children

stay active and

healthy.

Consumption of animal source

food is at the minimum. What

can be done to improve

current status, particularly of

chickens and eggs, and

increase the ‘mewekel’

culture?

3 Dark-green leafy

vegetables : ‘aiderkie’ ,

chard, shiferaw (good

sources of iron.)

Will help your

baby grow strong.

What other dark green

vegetables are there and how

can they be made more

accessible?

4 Ripe orange-coloured

fruits and vegetables:

papayas, mangos,

bananas, avocados

pumpkin, and carrot,

(good sources of vitamin

A).

Help the child to

have healthy eyes

and fewer

infections.

What other ripe-coloured

fruits and vegetables are there

and how can they be made

more accessible?

5 Oils, fats and sugars

(good sources of energy).

Provide energy. Among the least consumed

food items in the Dessie Zuria.

What can be done to promote

use?

6 Other fruits and

Vegetables

Provide

protection from

illness.

7 Iodized salt For mental

development.

44

Activity 5.3: Preparation of CF recipe and practical demonstration session describing father’s role (120

minutes)

Explain the importance of demonstrations in gaining practical skills.

Form groups with five members in each.

Assign half of the groups to prepare complementary foods for 6-11 months and the other half for

12-24 months using recipes selected from the Complementary Feeding Recipes for Ethiopian

Children 6-23 Months old; A Practical Cooking and Feeding Guide, based on the woreda context.

Ask the participants to choose one or two key messages which are relevant to the child for whom

they are preparing the meal.

Ask one participant in each group to make presentations explaining:

o When and where should the recipe preparation be demonstrated?

o What barriers do they anticipate with regards to demonstrating these foods when they

return to their community?

o Why did they chose the food that they prepared?

o Why should the food be prepared as suggested on the recipe book?

After the presentation facilitate discussion on how they will solve the anticipated barriers.


To teach a new skill or behaviour, you could:

Tell the caregiver how to do it - this is good, but the caregiver might not understand all of what

you have told her or may not remember it.

Have the caregiver watch while you talk and prepare the food - this is better than just telling

the caregiver what to do, because seeing and hearing together increases the likelihood of

remembering.

Help the caregiver to actually prepare the food themselves - this is the BEST method, because

the caregiver is doing the activity, so will have greater understanding.

Demonstration of preparation of complementary foods is a good way of transferring key

messages such as: how complementary foods should be prepared, what ingredients should

be mixed with the common staple food , what consistency complementary foods should have

and what amount should be given to the child.

Complementary food preparation can be during HEW house visit, DA composite preparation,

45

PSNP working days, women’s support group visit, community conversation sessions, VCHW

training and other contact as appropriate.

However, it is easier to remember a newly acquired message if the caregiver actually prepares

the food her/himself.

Meal preparations should not take more than 10 minutes since caregivers prepare meals

quickly.

Guide for planning group demonstration for the preparation of complementary foods

I. Before demonstration sessions

Gather the equipment and materials

Ingredients required to prepare complementary food (local mixed flour, cabbage or other

vegetables, egg, milk, iodized salt, water, oil/butter, dried meat)

Plates and utensils (spoons, pot, mixer, choping board, knife) for cooking and tasting the

prepared food.

Table on which to prepare the food.

Stove and fuel source.

Facilities for washing hands with soap.

Review objectives of the demonstration

Train caregivers how to prepare a simple and nutritious food for young children using local

ingredients (to learn through doing).

Demonstrate to caregivers the appropriate consistency and amount (thick) for these foods.

Demonstrate the taste and acceptability of the prepared food.

Decide on the key messages

Select 1 to 3 key messages for caretakers and after each message ask open ended questions related to

the message delivered to check if caregivers have understood and remember the message.

For example:

Foods that are thick enough to stay in the spoon give more energy to the child.

Question:

What should the consistency of foods for a small child be?

Answer:

Thick, so that the food stays in the spoon and doesn’t run off.

47

Describe role of fathers on complimentery food preparation

Father are responsible in provision of ingredients like egg, oil, iodized salt, meat, and vegetables

to enrich the porrige.

Most of the time, fathers are the main source of income for the family so they can assure the

family food security status.

Fathers should support child feeding and caring.

Fathers have to allow care takers /mothers resting time.

Fathers need to actively participate in all feeding actions.

Activity 5.4: Roles of FSTF to improve complementary feeding practices from 6 – 24 months (60 mins)

Divide participants into 4 working groups

Give one of the following questions for each group:

1. How do you think FSTF helps mothers/caregivers/ parents to improve complementary

feeding practices and make sure their children are properly fed?

2. What should be done if some food items are less available and less consumed in Dessie

Zuria?

3. When would a FSTF support mothers to improve a complementary feeding practice? (entry

points)

4. Which questions should be asked of mothers whose baby will soon be 6 months old?

Presentation by the groups.

Discussion and summarise (refer to facilitator’s note for possible answers).

48

Facilitator’s note: possible answers to questions

1. How do you think FSTF help mothers/care givers/ parents to improve complementary feeding

practices and make sure their children are properly fed?

Discuss the child feeding recommendations with the mother, the father, the

grandmother, the family (if possible) of the child according to the child’s age.

Congratulate and encourage the mothers/caregivers.

Encourage parents to grow and give food rich in vitamin A and iron to their children.

Encourage parents to bring their children to the health facility in case of malnutrition,

weight loss or oedema.

Encourage parents to have a garden with different green leafy vegetables, and

orange/yellow vegetables and fruits.

Raise awareness among population to use only iodized salt.

Encourage parents to call on support groups if difficulties occur.

Encourage parents to go to the health facility or community out-reach for immunisation

(measles at 9 months), for vitamin A and de-worming starting from 2 years.

Encourage the use of mosquito nets to protect child/mother/families against malaria.

2. What should be done if some food items are less available and less consumed in Dessie Zuria?

Exchange suggested food items for others that are more available.

Preserve seasonal vegetables and fruits.

Encourage communities to cultivate diversified food items.

3. When would a FSTF support mothers to improve complementary feeding practice?

During cash transfer days.

During PSNP working days.

During meetings.

During household visits.

4. Which questions should be asked of mothers whose baby will soon be 6 months old?

How do you feed your child?

What do you feed your child?

How often do you feed your child?

What amount do you feed your child?

Has your child received vitamin A supplements?

When will you come back for the next vitamin A intake?

Are your child’s immunisations up to date?

49

SESSION SIX: FEEDING OF SICK CHILD AND REFERRAL LINKAGE TO

CMAM AND OTHER SERVICES

Learning objectives


Describe the recommended feeding during illness and recovery.

Advise on child feeding during and after illness.

Explain the reasons for key practices regarding feeding of a sick child.

Explain the role of FSTF members in referring a sick /malnourished child.

Activity overview

Activity 6.1 Group work on feeding of the sick child. (45 minutes)

Activity 6.2 Signs of severe acute malnutrition. Referral linkages to CMAM and other

services. (15 minutes)


Materials needed


Advance preparation

Prepare and review flip chart presentation

Read and rehearse each step of the activity

Make enough copies of participants’ handouts

Prepare group exercises

Hand outs HO 6A: Feeding of the sick child key messages

50


Activity 6.1: Group work on feeding of the sick child (45 minutes)

Set-up 6 flipcharts throughout the room and divide participants into 2 teams of 3; each group will

spend 5 minutes at each flipchart answering the following:

1. Advice on feeding 0 – < 6 month old and 6 – 24 month old during illness;

2. Advice on feeding 0 – < 6 month old and 6 – 24 month old after illness; and

3. Advice on feeding the malnourished child.

Groups do not repeat the same information, but only add new information.

After 5 minutes the groups rotate to another flipchart.

Each team presents in plenary.

Discussion and summary using key messages on feeding of the sick child, HO 6A.


Possible Answers for Activity 6.1

1) Advice on feeding sick child during illness:

Child under 6 months:

If the baby is sick, particularly with diarrheoa, the mother increases

breastfeeding frequency and continues exclusive breastfeeding to

avoid dehydration and malnutrition.

Breast milk contains water, sugar, nutrients, and salts in adequate

quantities, which will help the baby recover quickly from diarrheoa.

If the baby has severe diarrheoa, the mother should continue to

breastfeed and go to the health centre for advice and treatment. If

dehydrated, baby will need ORS.

Child older than 6 months:

If the young child is sick, the mother should breastfeed

frequently to avoid dehydration and malnutrition. She should

also offer the baby’s favourite food (even if the baby is not

hungry).

If the baby has severe diarrheoa and shows any signs of

dehydration, the mother should continue to breastfeed and go

to the health facility for advice and ORS treatment.

51

2) Advice on feeding sick child after illness:

Child under 6 months:

Continue to breastfeed exclusively, and breastfeed more frequently for at least 2 weeks after

illness.

Breast milk contains all the nutrients to help the baby regain strength and weight loss.

Child older than 6 months:

The mother should breastfeed more frequently, and daily offer an extra meal or snack for a

period of 2 weeks.

3) Advice on feeding the malnourished child

Advise as if the child was a sick child (breastfeeding and complementary feeding). Encourage the

mother to actively feed her child so that child finishes his/her food.

Refer the mother to a Supplemental Food Distribution Centre or a Therapeutic Feeding Centre.

Refer to HO 6A on feeding of the sick child

52

HO 6A: Key messages for feeding of sick child

Infants 0 to 6 months

Mother and

father

During illness, increase the frequency of breastfeeding for your baby to recover

faster.

Supporting

information

Continue to breastfeed during diarrheoa, even increasing the frequency, to

replace the liquid lost.

Breastfeeding more during illness will help your baby to fight the sickness and not

lose weight.

Breastfeeding also provides comfort to a sick baby.

Sick mothers can continue to breastfeed their baby.

Mother After each illness increase the frequency of breastfeeding for the baby to regain

health and weight.

Supporting

information

Each time a baby is sick, it will lose weight so it is important to breastfeed as often

as possible.

Your breast milk is the safest and most important food you can offer your baby to

regain its health and weight.

Children 6 to 24 months

Mother and

father

During illness, increase the frequency of breastfeeding and offer additional food

to your child to help it recover faster.

Supporting

information

Fluid and food requirements are higher during illness.

Take time to patiently encourage your sick child to eat as their appetite may be

decreased because of the illness.

It is easier for a sick child to eat small frequent meals so feed the child foods it

likes in small quantities throughout the day.

It is important to keep breastfeeding and feeding complementary foods to your

child during illness to maintain its strength and reduce the weight loss.

Mother and

father

When your child has recovered from an illness, give it one additional meal of solid

food each day during the two weeks that follow to help it recover quickly.


Children who have been sick need extra food and should be breastfed more frequently to regain the strength and weight lost during the illness.

Take enough time to actively encourage your child to eat this extra food as they still may not appear hungry due to the illness.

53

Activity 6.2: Signs of severe acute malnutrition, referral linkages to CMAM and other services. (15

minutes)

Ask participants how a mother with a severely malnourished child can be identified and supported

in PSNP? For example: giving sick leave.

Ask participants what they do when they find a severely malnourished or sick child?

Remind them to refer urgently to health facility, CMAM, GMP, CBN, TSFP and other available

services in their locality.


Malnutrition often is invisible and remains unrecognised in the majority of children in Ethiopia.

Acute malnutrition is the term used to cover both wasting and nutritional oedema (also known as kwashiorkor or oedematous malnutrition).

Acute malnutrition results from a decrease in food consumption and/or illness resulting in sudden weight loss or bilateral nutritional oedema.

Acute malnutrition is classified into a) moderate acute malnutrition (MAM) and b) severe acute malnutrition (SAM), according to the degree of wasting and the presence of oedema.

Moderate Acute Malnutrition (MAM): A child aged 6 months to 5 years has moderate acute malnutrition if the following is present:

A mid-upper-arm circumference (MUAC) of ≥11.0 cm but <12 cm and no pitting oedema of both feet.

Severe Acute Malnutrition (SAM): A child aged 6 months to 5 years has severe acute malnutrition if the following is present:

MUAC of < 11.0 cm or

Presence of pitting oedema of both feet. A child aged less than 6 months has severe acute malnutrition if the following is present:

Visible severe wasting or

Presence of pitting oedema of both feet

Note: One should not wait for these signs to appear before acting because they are signs of ns of severe acute malnutrition, meaning that the child is in great danger.

Refer the mother to a health facility.

If you identify SAM refer immediately to a health facility.

54

SESSION SEVEN: WOMEN’S NUTRITION

Learning objectives


Explain women’s nutrition to promote family health.

Explain how to improve child survival through women’s nutrition.

Explain the intergenerational cycle of malnutrition.

Negotiate with women to encourage optimal nutrition practices for themselves.

Explain roles of FSTF in improving maternal nutrition.

Activity overview

Activity 7.1: Discuss findings on women’s nutrition from IYCF baseline survey and TIPs study

in Dessie Zuria. (15 minutes)

Activity 7.2: Describe importance of promoting adequate feeding for women, and

explanation of the intergenerational malnutrition cycle. (10 minutes)

Activity 7.3: Discuss interventions that can be used to break the malnutrition life cycle. (45

minutes)

Activity 7.4: Discuss roles of FSTF to improve maternal nutrition. (20 minutes)


Materials needed

Flipchart papers, markers and masking tape

Drawing of malnutrition life cycle on flipchart

Advance preparation

Prepare summary of Dessie Zuria TIPs findings on woman’s nutrition and summary of IYCF

baseline survey.

Read and rehearse each step of the session, prepare group exercises.

Make enough copies of participants’ handouts

55

Hand outs

HO 7A: Summary result of feeding for pregnant and lactating women from TIPs and IYCF baseline survey

HO 7B: Intergenerational cycle of malnutrition

HO 7C: Interventions to break the malnutrition cycle

HO 7D: Key messages for Ethiopia on women’s nutrition


Activity 7.1: Findings on women’s nutrition from IYCF baseline survey and TIPs study in Dessie

Zuria. (15 minutes)

Ask participants about the pre and post natal nutrition practices in the communities where they

live/work.

Discuss the results of woman’s nutrition from Dessie Zuria assessment (Discuss only the areas

relevant to the participants’ areas of work) – HO 7A

How do you think you can address some of the gaps and misconception? Who will be the sector

responsible for improving these gaps?


HO 7A: Summary - feeding for pregnant and lactating women from TIPs and IYCF baseline survey

No additional food given during pregnancy.

Mothers perceive that beans, chick peas, barley, wheat, oat (prepared in a form of gruel) and

meat are healthy foods for pregnant mothers while green pepper and kale are labeled as

unhealthy. Kale is believed to prolong labour.

The mothers also recounted that till late pregnancy, they continue to engage in routine

household chores.

When they start to get obviously weak, they get support from their family which usually

happens around the eighth month.

Low attendance of antenatal care.

Mothers are exempted from PSNP during this period, their quota covered by their husbands.

Lactating mothers in the community are provided with supportive care extending to a maximum

of forty days. The mother is also exempted from household chores during this time.

Frequency of feeding by lactating mothers is also increased to four to five times per day during

post natal period, up to 40 days.

Mothers also exempted from public works of the safety net programme during lactation.

56

Activity 7.2 Importance of promoting adequate feeding for women, and explanation of the

intergenerational malnutrition cycle. (10 minutes)

Brainstorm the questions

- Why is it important to promote adequate feeding for women?

- How can we improve women’s nutrition in relation with PSNP?

Write answers on flipchart and discuss.

Facilitator explains the intergenerational malnutrition cycle. (HO 7B)

HO 7B: Intergenerational cycle of malnutrition

Intergenerational Cycle of Malnutrition

When a woman is malnourished, the next generation may also suffer from malnutrition and poor

health. Malnourished women can result from:

Girls that are underweight at birth.

Girls that are underweight and stunted.

Girls that have their first pregnancy during adolescence.

Women who are undernourished, have close spaced pregnancies, and have heavy workloads

during pregnancy and breastfeeding periods.

57

Activity 7.3: Interventions that can be used to break the malnutrition life cycle. (45 minutes)

Divide participants into 4 groups and ask each group to focus on one point in the malnutrition

life cycle (one arrow) and develop strategies to break the cycle at that point.

Each group will present their work in plenary.


Refer to handouts (7C and 7D) and discuss.

Summary: Initiatives aiming to improve child survival must start long before conception. They

should start by improving the woman’s health status, and solving her economic and social

problems.

Low birth

weight

Low weight &

height of the

child (growth

failure)

Adolescent

girl with low

weight &

height

Woman

with low

weight &

height

Teenage pregnancy

58

HO 7C: Interventions to break the malnutrition cycle

Interventions to break the malnutrition cycle

1. Prevent low weight and height of the child (growth failure)

Early initiation of breastfeeding.

Exclusive breastfeeding 0 - < 6 months.

Optimal complementary feeding at 6 months with continuation of breastfeeding up to 2

years.

Feed sick child during illness and 2 weeks after recovery.

Vitamin A supplementation and consumption of foods rich in vitamin A.

Iron supplementation, de-worming and consumption of foods rich in iron.

Iodine salt consumption.

2. Prevent low weight and height of adolescent girl

Increase the food intake of adolescents.

Prevent and educate on early marriage.

Prevent and treat infections.

Education on STIs and HIV and AIDS transmission.

Prevent iron, vitamin A and iodine deficiencies:

o Encourage consumption of foods rich in iron (green leafy vegetables, meat, and liver).

o Encourage consumption of foods rich in vitamin A (papaya, mangoes, carrots,

pumpkins, liver).

o Encourage consumption of iodized salt and foods rich in iodine (fish and seafood).

Encourage parents to give equal access to education to boys and girls (schooling of the girl

child).

3. Prevent low weight & height of woman

Improve woman’s nutrition and health:

Increase the food intake of the woman at every step of her life, especially during

adolescence, pregnancy or while breastfeeding: an additional meal, more food than

usual, and a varied diet.

Fight iron, vitamin A and iodine deficiencies:

o Iron/folic acid supplementation during pregnancy, (1 tablet/day during 6 months).

o Encourage consumption of foods rich in iron (green leafy vegetables, meat, and

liver).

o Vitamin A supplementation after delivery (a single dose [1 capsule of 200,000IU]

within 6 weeks after delivery).

o Encourage consumption of foods rich in vitamin A (papaya, mangoes, carrots,

pumpkins, liver).

o Encourage consumption of iodized salt and foods rich in iodine (fish and seafood).

59

Prevent and treat infections:

o Use of insecticide treated bed nets

o De-worming of pregnant women during 3rd trimester.

o Education on STI and HIV an AIDS transmission and prevention.

Family planning (for delay first pregnancy and birth spacing).

Decrease energy expenditure:

Delay the first pregnancy up to 20 years old or more.

Encourage couples to use family planning.

Decrease pregnant and breastfeeding women’s workload.

Rest more.

Encourage men’s participation:

In birth spacing, and good follow-up of pregnancy and delivery.

In supporting better feeding and a lighter workload for their wife/partner.

Encourage parents to give equal access to education to boys and girls (schooling of the

girl child):

Risk of malnutrition decreases when girls/women receive a higher level of education.

HO 7D: Key messages for Ethiopia on women’s nutrition

1. Husband Ensure that your pregnant wife has one additional meal every day to maintain her

strength.

Supporting

information

Pregnant women need to eat a variety of foods, particularly animal products

(meat, milk, eggs, etc), plus fruits & vegetables.

Ripe papaya & mango, orange, carrot & pumpkin are especially good.

Pregnant women need to eat more food than usual rather than decrease their

intake.

2. Husband Make sure your pregnant wife gets iron/folate tablets to maintain her strength

during the pregnancy.

Supporting

information

Ask a Health Worker for iron/folate tablets to be given to your pregnant wife over

a six month period.

The six month course of iron/folate tablets can carry over even after the birth of

the baby.

Pregnant women have increased needs for iron.

Iron/folate pills are important to prevent anaemia in a pregnant woman and will

help to keep her and the new baby healthy.

Liver is also a good food source of iron for pregnant women.

3. Husband Make sure your pregnant wife gets de-worming pills once in the second or third

trimester of pregnancy.

60

Supporting

information

Ask a Health Worker for mebendazole (500 mg) to be given once to your pregnant

wife in the second or third trimester of pregnancy.

Intestinal worms can cause anaemia which leads to tiredness and poor health.

4. Husband Ensure that your wife who is breastfeeding has two extra meals a day to maintain

her health and the health of the baby.

Supporting

information

To maintain their health, breastfeeding women need to eat a wide variety of

foods, particularly, animal products (meat, milk, eggs, etc), fruits and vegetables.

Ripe papaya & mango, orange, carrot, and pumpkin are especially good for the

mother.

5. Mother Take vitamin A supplementation within 45 days of delivery for the baby’s health and

strength.

Supporting

information

Ask a Health Worker for vitamin A supplementation after the birth of the baby.

Taking a vitamin A capsule will enrich the mother’s breast milk with important

nutrients to keep the baby healthy and strong.

6.All family

members

Sleep under insecticide treated net (INT), especially pregnant women and children,

to prevent getting malaria.

Supporting

information

Malaria causes anaemia which will make members of your family unwell and very

tired.

Family members with fever need to be taken to a health facility.

Activity 7.4: Roles of FSTF to improve maternal nutrition. (20 minutes)

Ask participants:

1. What are the roles of different sectors in improving maternal nutrition?

2. Do you think adult education programmes can have an effect on maternal nutrition?

3. Which household activity do you think is more laborious? How can we address maternal workload?

Emphasis on : Delayed marriage, access to education, use of local technologies in reduction of maternal work load, micronutrient supplementation.

Summary and discussion

61

SESSION EIGHT: BEHAVIOUR CHANGE COMMUNICATION AND

COUNSELLING SKILLS

Learning objectives


Define behaviour change communication.

Explain the stages of behavioural change.

Practice counselling and negotiation skills on feeding practices with mothers and care givers.

Learn to organise mini drama edutainment sessions in the community.

Activity Overview

Activity 8.1 Define BCC and explain why knowledge is usually never enough to change

behaviour. (10 minutes)

Activity 8.2 Stages of behaviour change communication and interventions required at each

step of the change. (10 minutes)

Activity 8.3 Practice identifying what behaviour change stage a mother is in with regards to

her infant feeding practices. (20 minutes)

Activity 8.4 Presentation and practice of counselling negotiation steps – ALIDRAA. (60

minutes)

Activity 8.5 Organise a mini drama edutainment session in the community. (20 minutes)


Materials needed


Advance preparation

Read and rehearse each steps of the session.


Hand outs

HO 8A: Stage of change model.

62

HO 8B: Stages of change and Interventions.

HO 8C: Listening and learning skills.

HO 8D: Observation checklist: counselling and negotiation initial visit (ALIDRAA).


Activity 8.1 Define BCC and explain why knowledge is usually never enough to change behaviour.

(10 minutes)

Brainstorm the definition of behaviour change communication (BCC).

Ask participants to think about a time when they wanted to change a certain behaviour in their

life. Ask them what triggered the need to change the behaviour and how they felt about it at the

start of it.

Ask participants if they were successful in changing and maintaining their behaviour.

Ask them what were the barriers and facilitators of adapting the behaviour.

Discuss the influences they encountered from their social environment, like family, friends,

community and services provider etc.

In plenary discuss the major points discussed among the group. Ask a few participants to share

their feelings and experiences voluntarily.

Discuss how information is usually never enough to change their behaviour.


Behaviour = action/doing.

Change = always involves motivators and barriers/obstacles.

Communication = interpersonal, visuals, media, etc.

Behaviour change communication (BCC) is any communication (e.g., interpersonal, group talks,

mass media, support groups, visuals and print materials, videos) that helps foster a change in

behaviour in individuals, families, or communities.

Activity 8.2 Stages of behaviour change communication and interventions required at each step of the

change. (10 minutes)

On flip-chart draw steps and brainstorm with participants how one generally moves through the

different stages of behaviour change (use exclusive breastfeeding and complementary feeding

63

practices as an example).

Distribute and discuss HOs 8A and 8B: stages of change model and stages of change and

interventions

Ask participants to close their eyes and think about behaviour they are trying to change. Ask

them to identify at what stage they are and why. Ask what they think they will need to move to

the next stage.

Refer to handouts (HO 8A & HO 8B) and discuss

HO 8A: Stage of change model

Stages of Change Model

Steps a person

or group takes

to change their

practices

Pre-awareness

Awareness

Contemplation

Intention

Trial

Adoption

Maintenance

Telling

others

Persuasion

Information

Encouragement

Negotiate

Discuss

benefits

Support

Praise

64

HO 8B: Stages of change and interventions

Steps Appropriate interventions

To convince the target audience to try new practices – to provide support

for the mother’s choice and change community norms.

Never having heard

about the behaviour

Build awareness/provide information

Drama, edutainment.

Community groups.

Radio.

Individual counselling.

Breastfeeding and Young Child Feeding Mothers’ Support Groups.

Having heard about

the new behaviour

or knowing what it

is

Encourage/discuss benefits

Group discussions or talks.

Oral and printed information.

Counselling cards.

Breastfeeding and Young Child Feeding Mothers’ Support Groups.

Thinking about new

behaviour

Negotiate and help to overcome obstacles

Home visits, use of visuals.

Groups of activities for family and the community.

Negotiate with the husband and mother-in-law (or other influential

family members) to support the mother.

Trying new

behaviour out

Praise/reinforce the benefits

Congratulate mother and other family members as appropriate.

Suggest support groups to visit or join to provide encouragement.

Encourage community members to provide support (radio

programmes).

Continuing to do

new behaviour or

maintaining it

Provide support at all levels

Reinforce the benefits.

Praise.

65

Activity 8.3 Practice identifying what behaviour change stage a mother is in with regards to her infant

feeding practices. (20 minutes)

Divide into 3 working groups – give each group 3 case studies. Group identifies which stage

mother is in. Each group presents one case study.

Ask also in which stage of change is the community for the various IYCF practices (BF, CF, and

maternal nutrition) and ask what interventions are important. They can refer to the handouts

and discuss.

Discussion in plenary.

Behaviour change case studies

1. A woman has heard the new breastfeeding information, and her husband and mother-in-law

also are talking about it. She is thinking about trying exclusive breastfeeding because she thinks

it will be best for her child.

2. A woman has brought her 8–month-old child to the baby weighing session. The child has lost

weight. The health care worker tells her to give her child different food because the child is not

growing.

3. In the past month a health worker talked with a mother about gradually starting to feed her 7–

month-old baby three times a day instead of just once a day. The mother started to give a meal

and a snack and then added a third feed. Now the baby wants to eat three times a day.

Behaviour change case studies (answer key)

1. A woman has heard the new breastfeeding information, and her husband and mother-in-law

also are talking about it. She is thinking about trying exclusive breastfeeding because she thinks

it will be best for her child.

Contemplation/Intention

2. A woman has brought her 8–month-old child to the baby weighing session. The child has lost

weight. The health care worker tells her to give her child diversified food because the child is

not growing.

Awareness

3. In the past month a health worker talked with a mother about gradually starting to feed her 7–

month-old baby three times a day instead of just once a day. The mother started to give a meal

and a snack and then added a third feed. Now the baby wants to eat three times a day.

Trial/Adoption

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Activity 8.4 Presentation and practice of counselling and negotiation skills – ALIDRAA. (60 minutes)

In plenary ask participants: what are the different steps of negotiation and counselling? And

how many visits are needed for the full process of counselling negotiation? Write answers on

flipchart.

Brainstorm additional points to be discussed with mother during negotiation for follow-up

visit(s).

Add any missing information.

Review listening and learning skills.

Presentation of the steps of negotiation: Asks, Listens, Discusses, Recommends and Negotiates,

Agrees and Repeats agreed upon action, follow-up Appointment (ALIDRAA).

Refer to handout (HO 8C and 8D) and discuss: general case studies of baby 0 - 6 months

Practice

Asks participants to recall the optimal breastfeeding and complementary feeding practices.

Participants are divided into threes: mother, CW (or HEW), and observer; each group is given

one of 3 case studies to practice counselling and negotiation in an initial visit; each participant

rotates the 3 different roles.

Two groups demonstrate a case study in plenary.


HO 8C: Listening and learning skills.

1. Use helpful non-verbal communication

a. Keep your head level with mother

b. Pay attention

c. Remove barriers

d. Take time

e. Appropriate touch

2. Ask open questions

3. Use responses and gestures that show interest

4. Reflect back what the mother says

5. Empathise – show that you understand how she feels

6. Avoid using words that sound judgmental

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HO 8D: Observation checklist: counselling and negotiation initial visit. (ALIDRAA)

1. Greets the mother and establish confidence.

2. Asks the mother about current breastfeeding or complementary practices.

3. Listens to the mother.

4. Identifies feeding difficulty, if any, causes of the difficulty, and selects with the mother the

difficulty to work on.

5. Discusses with the mother different feasible options to overcome the difficulty.

6. Recommends and negotiates doable actions: presents options and helps mother select one

that she can try.

7. Mother Agrees to try one of the options, and mother repeats the agreed upon action.

8. Makes an Appointment for the follow-up visit.

How many visits are needed for the full process of counselling and negotiation?

At least 2 visits:

- Initial visit

- Follow-up: after 1 to 2 weeks

- If possible a 3rd visit to maintain the practice or negotiate another practice


Negotiation follow-up visit(s)

Asks whether the mother tried (or continued) the agreed practice.

Congratulates her for trying (or continuing) the new practice.

Asks what happened when she tried (or continued) the new practice.

Asks whether she made any changes to the new practice and why?

Asks what difficulties she had, how she solved them, or helps her find ways to solve the

difficulties she might have had.

Listens to the mother’s questions, concerns and doubts.

Asks whether she likes the practice agreed on and if she thinks she will continue.

Praises the mother and motivates her to continue the practice.

Reminds the mother to take the child to be weighed (attend well-baby clinic).

Tells the mother where she can get support from health extension workers, health centres, or

mother support groups.

Agrees on a date for the next visit

Depending on the age of the child:

- talks to the mother about a new practice.

- encourages the mother to try a new practice (process of ALIDRAA).

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Possible answers: practice case studies

The participants are expected to follow the negotiations steps [ALIDRAA] and use the listening and

learning skills.

Greets the mother and establishes confidence.

Asks the mother about current feeding practices.

Listens to the mother.

Identifies feeding difficulty, if any, causes of the difficulty, and selects with the mother the

difficulty to work on.

Discusses with the mother different feasible options to overcome the difficulty.

Recommends and negotiates doable actions: presents options and helps mother select one that

she can try.

Mother Agrees to try one of the options, and mother repeats the agreed upon action.

Makes an Appointment for the follow-up visit.

Case Study #1 (Breastfeeding):

You visit a new mother, Tesfa, who has a newborn son. She is breastfeeding and her mother-in-law

insists that she give water to her grandson.

Answer

The participant has to ask and listen to the current feeding practices and identify problems and causes

for the problems.

In this particular case the main problem that has to be identified is giving water, the reason being the

grandmother insisted that the mother do so. The participant has to ask why the grandmother thinks that

the baby should take water. S/he also has to ask the mother whether she has been giving water or not.

The participant has to explain:

The availability of adequate water for the baby in the breast milk, demonstrated by the baby passing

urine six or more times in 24 hrs.

The risks of giving water to the baby: risk of diarrheoa, baby's stomach getting full with water and

feeding less, losing weight, infrequent feeding leading to decreased breast milk production

S/he has to recommend, negotiate and agree with the mother to try practicing EBF for about 2-3

days and make an appointment for a later date. S/he needs to talk to the grandmother. S/he

praises the mother for her time.

Case Study #2 (CF):

You are Tsega. Your son, Mamush, is 18 months old. You are breastfeeding once or twice a day. You are

giving Mamush milk and cereal 2 times a day.

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Answer

Greet Tsega and ask questions that encourage her to talk, using listening and learning, building

confidence and giving support skills. Complete IYCF Assessment of Mother/Child Pair. Observe Tsega and

Mamush’s general condition and listen to Tsega’s concerns. Accept what Tsega is doing without

disagreeing or agreeing.

Tsega is breastfeeding Mamush and Tsega is giving another milk to Mamush. Tsega is not

following age-appropriate feeding recommendations (e.g. variety and frequency).

Praise Tsega about continuing breastfeeding. Talk with Tsega about the characteristics of

complementary feeding: variety, texture (thickness/ consistency), frequency, amount,

active/responsive feeding, and hygiene.

Present options/small do-able actions (time-bound) to overcome the difficulty of inadequate

complementary foods, e.g. increase feeding frequency of foods to 4 times a day; ask about the

amount of cereal Mamush receives and the possibility of increasing the amount; ask about the

texture (thickness/consistency) of the cereal, and add other locally available family foods and

help Tsega select one or two that she can try or that she believes will be possible for her and she

is willing to try.

Counsellor will select the portion of the information on the age-appropriate counselling card

that is most relevant to Mamush's situation -- and discuss that information with Tsega.

Ask Tsega to repeat the agreed upon behaviour. Tell Tsega that you will follow-up with her at

her next weekly visit. Suggest where Tsega can find support (attend educational talk, IYCF

Support Group in community, Supplementary Food Programme, and refer to Community

Worker). Refer as necessary. Thank Tsega for her time. Discuss the demonstration with

participants. Answer questions.

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Activity 8.5 Organise a mini drama edutainment session in the community. (20 minutes)

Conduct a mini drama using the case below: role play the mini drama by assigning facilitators and/or

participants to the different roles.

At the end of mini drama ask the participants/community members:

1. What would you do in the same situation? Why?

2. What difficulties might you experience?

3. How would you be able to overcome them?

4. What practical help would you give?

Then, ask the following questions of the participants:

1. What did you like about the action-oriented group session?

2. How was this group session different from an educational talk?

Discuss and summarise the session.

Mini-drama case study

Mother:

Your baby is 7 months old and you are giving him porridge once a day. You are afraid your husband may

not agree to buy any more food.

Husband:

You do not think that your wife needs money to buy anything extra for your child.

Health Extension Worker:

You are doing a home visit. You help the mother and father identify foods they can give the baby and

increase to three times the number of feeds each day. (IYCF counselling card, family health card)

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Case Study Checklist

Visit #1: Initial Visit

Checklist of ALIDRAA

▪ Ask about feeding practices, age of the child and status.

Listen to the mother.

Identify feeding difficulties and causes of the difficulties.

Discuss different feasible options with the mother.

Recommend and negotiate doable actions.

Agree on which practice the mother will try; mother repeats agreed upon practice.

Appointment for follow-up.

Visit # 2: Follow up

Checklist of Visit #2

▪ Ask the mother if she has tried the practice she was willing to try.

(example: exclusively breastfeeding for one week)

▪ Congratulate her for trying the new practice.

▪ If she tried, what does she think of it?

▪ If she didn’t try the new practice, why not?

▪ What changes did she make to the recommended practice and why?

▪ What did she like about the practice?

▪ Which difficulties did she encounter?

▪ Discuss the same recommendations or other ones with the mother.

▪ Inform the mother of the nearest place where she can find support.

▪ Plan with mother a follow up visit.

Visit #3: Maintain the practice and/or negotiate new practice

Before making the visit, check the child’s age. According to the child’s age, should the mother keep

the current practice or should she begin a new one?

Checklist of Visit #3: Maintain the practice

▪ Ask the mother if she has continued with the new practice.

▪ Congratulate her if she has.

▪ If she has not, why?

▪ Which changes did she make and why?

▪ What were the difficulties?

▪ How did she solve them?

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▪ Listen to the mother’s questions, concerns, and doubts.

▪ Discuss the same recommendations or new ones with the mother. For example, if the

new practice was exclusive breastfeeding, remind the mother that when her baby

reaches the age of 6 months, she must give other foods besides breast milk to her baby

(show her the poster on feeding of children 6 - 24 months and share the messages).

Checklist of Visit #3: Negotiate a new practice

▪ Encourage the mother to try a new practice.

▪ Ask her which recommendation she thinks she can carry out.

▪ Does she think she can practice it every day?

▪ If she thinks she can do it twice a week and do another practice for the rest of the week,

encourage her to try it

▪ Inform the mother of the nearest place where she can find support.

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SESSION NINE: COMMUNITY BASED INFORMATION SYSTEM

(RECORDING, USE OF DATA AND REPORTING) AND FIELD VISIT

Learning objectives

By the end of this session, participants will be able to:

Recognise the importance of community based information systems.

Describe how data is collected, managed and utilised at community level to improve performance

(data for decision making).

Describe how to monitor and follow the integration of PSNP and IYCF at the Woreda and Kebele

level, describe roles of partners in monitoring and reporting the project.

Activity overview:

Activity 9.1: Discuss importance of data and information. (30 minutes)

Activity 9.2: Describe recording and use of data for decision-making. (60 minutes)

Activity9.3: Field visit. (60 minutes)

Total time: 150 minuites

Materials needed:

Flipchart paper

Marker

Pencil and eraser

Advance preparation

Make sufficient copies of supervision check list / recording and reporting forms.

Prepare flipcharts with text from HO 9A, 9B, 9C.

Hand outs

HO 9A: Role of the FSTF in CBIS.

HO 9B: Role of voluntary community health workers (VCHWs) in CBIS.

HO 9C: Purpose of analysing and using data for decision making.

HO 9D: The community IYCF/PSNP supportive supervision checklist

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Activity 9.1: Importance of data and information. (30 minutes)

Brainstorm in plenary the importance of data/information, follow up and monitoring.

Ask participants to reflect on why we need to collect data and generate information from

implementing community activities?

Make sure one or more of the following points are raised and discussed:

o To keep record of what has been done.

o To inform others about activities accomplished.

o To track progress in activity implementation.

o To identify gaps and take corrective measures.

o To use as a resource for future planning.

o To make sure of proper use of resources etc.

Briefly describe what community based information system (CBIS) means, monitoring, follow up

and roles of FSTF and explain with examples.

Ask participants what the potential role of FSTF will be in community based information system.

Co – facilitator should list the responses on a blank flip chart.

Summarise the activity by reminding the participants of the importance of CBIS and the role of

FSTF in CBIS. Use flip chart text 9A and 9B.

HO 9A: Role of the FSTF in CBIS

Support, mentor and encourage the VCHWs in the data collection process.

Support VCHWs to properly register IYCF/PSNP data/information and report on them by

using the standard format.

Provide technical assistance for VCHWs on recording, data use and reporting based on gaps.

Organise and conduct group meeting with VCHWs and discuss and identify actions based on

the analysis of the data provided by VCHWs.

Analyse Kebele level data from different sources for presentation and discussion with the

community or other relevant body in collaboration with VCHWs and the health committee.

Assist the community to plan (for IYCF/PSNP activities) based on the findings of the data

reported by VCHWs.

Be involved in the monitoring and evaluation of the planned activities.

Compile the different data/information for the Kebele, prepare and submit report.

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HO 9B: Role of voluntary community health workers (VCHWs) in CBIS

Visit households and collect relevant data on IYCF/PSNP and report to FSTF.

Update their HH data based on information collected.

Undertake planned activities, record necessary data/information as per the standard

register/record provided and report to FSTFT.

Participate at group meetings organised by FSTF and share information and discuss the

data analysis results.

Activity 9.2: Recording and use of data for decisions. (60 minutes)

Explain what recording data for decision making refers to by sighting example from IYCF/PSNP

related activities.

In plenary, discuss methods of data collection, anticipated challenges and how to ensure quality of

the data to be collected at community level. Use the following questions: Guide the discussion to

focus on potential role and activities to be implemented at their level.

What information should be included in the register for IYCF/PSNP related activities at the level of VCHW/FSTF?

How do VCHWs/HEWs in the Kebele get information on IYCF/PSNP?

What are the different options to collect and share IYCF/PSNP information at community level?

What challenges are anticipated in collecting and sharing IYCF/PSNP related information at community level?

How can we ensure the quality and validity of the data collected?

In plenary, summarise the discussion by reinforcing correct responses and correct incomplete

responses. For issues that arise as challenges ask participants to share their ideas on how to

overcome challenges.

Tell participants that now you will discuss the use of data for decision making. Start by asking

participants in plenary why is it important to analyse and use data for decisions. Encourage them to

share their experience. Use the following guiding questions

What else do you do with collected data other than posting on the walls of your offices?

Have you ever discussed your data in relation to your plan with other people? If so with whom?

Do you think there is a need to evaluate our activities with other people in the community

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for problem solving and performance improvement?

After collecting participants’ responses, tell them that it is normal to collect data and compare

them with plans and display plan monitoring charts posted on walls of health institutions.

Introduce participants to HO 9D the Community IYCF/PSNP Supportive Supervision Checklist. Ask if

they have questions and emphasise the need to collect data on key IYCF/PSNP activities.

Summarise the session by reminding participants of the importance of regular recording of data,

timely review and analysis as well as use of data for decisions to improve performance. Use HO 9C

on flipchart.

Facilitator’s Note

Key IYCF areas for which data is needed

Early Initiation of breastfeeding.

Exclusive breast feeding under 6 months.

Continued breast feeding at 1 year.

Introduction of solid, semi-sold, soft food.

Minimum dietary diversity.

Minimum meal frequency.

Minimum acceptable diet.

Consumption of iron-rich foods.

Children ever breastfed.

Continued breastfeeding at 2 years.

Age-appropriate breastfeeding.

Maternal post-partum vitamin-A supplementation.

Provision of de-worming tablets for pregnant women.

Iron supplementation for pregnant women during pregnancy.

HO 9C: Purpose of analysing and using data for decision making

Helps to monitor progress towards planned implementation of a given activity.

Helps to identify level of performance towards a given target and compare with expected plan.

Helps to evaluate and identify gaps and plan next actions.

Help to compile and present information.

Helps to summarise accomplishments and report to concerned body.

Helps to measure the contribution of VCHWs/FSTF.

Improve FSTF/VCHWs credibility and recognition within the community.

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Activity 9.3: Field visit/supportive supervision. (60 minutes)

HO 9D: The community IYCF/PSNP supportive supervision checklist

Community IYCF/PSNP Supportive Supervision Checklist

Introduction: This form is for managers, project officers, community officers of FSTF and team members

to use while conducting supportive supervision of community IYCF/PSNP activities.

Primary data source: The primary source of data for completing the supervision form is monthly

meetings between FSTF, their WFSTF/HF, supervisors, IYCF/PSNP focal persons, and programme staff.

Backup/quality-check data source: To verify the quality of the self-reported data gathered from VCHWs,

it is suggested that supervisors make periodic checks with households with observation and other

checklists.

Woreda: Site: Date:

Name of Supervisor(s) Organization Signature

1

2

3

Activities to Be Supervised

A Performance of Activities as Planned

A1 2-3 Households visited per week

2 community conversation per

month

1 Edutainment per month

1 community meeting per month

1 other community mobilization

activitie

Yes No

Yes No

Yes No

Yes No

Yes No

# of session conducted ___





Comments and suggestions: Indicate the reason for any of the above activities marked “No.”

78

A2 Challenges encountered & action taken by Supervisors (WoHo or HC):

Problems

Solutions

B Referral Activities

Comments and suggestions: Indicate the reason for any gaps identified in referral activities.

B1 Are the health providers aware of the importance of community referral cards? Yes No

B2 If they are not aware of it please take the initiative and make them familiar with community

referral cards.

C Monthly/ Quarterly Meeting

C1 Are KFSTF supervisors conducting the monthly meeting at regular basis? Yes No

(This information can be accessed from documented meeting. Go through minutes and action

points discussed)

D Reporting and Feedback

D1 Are KFSTF reporting on monthly bases? Yes No

If yes, please indicate data quality checks you completed for this reporting period and

population.

Are DA/HEWS/VCHWs keeping records of all IYCF related activities? Yes No

If yes, please indicate data quality checks you completed for this reporting period and

population.

79

If No, please give the reason

E Comments and Suggestions

NB: This information shall be delivered to WFSTF within a week of the supervision for prompt feedback

and timely measure. The regional offices are also responsible for keeping the copy of each SS checklist

and their report.

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SESSION TEN: ACTION PLANNING

Objectives

At the end of the session, participants will be able to:

Explain the purpose of developing action plans.

Learn how to prepare an action plan.

Discuss and endorse the action plan of the project.

Explain roles of WFSTF in developing action plans for community activities.

Activity overview

Activity 10.1: Introduction to action planning. (20 minutes)

Activity 10.2: Action plan development. (40 minutes)

Total time: 60 minutes

Materials needed

Flipchart paper and marker

Pencil, eraser and masking tape

Action plan format (if the client has separate format, use client format)

Advance preparation

Prepare and duplicate sufficient copies of sample project action plan form. HO 10B

Prepare a flipchart with a drawing of the palm of the hand with the 5 key words of planning written

in each finger.

Hand outs

HO 10 A: Five friends of planning

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Activity 10.1: Introduction to action planning. (20 minutes)

Define what planning and action plan mean to participants and give examples.

Brainstorm in plenary some of the reasons for planning (Why planning is important?).

Explain the purpose of preparing community action planning in IYCF/PSNP context.

1. Using the five friends of planning diagram on flip chart HO 10 A, (the outline of the palm of

a hand, with the 5 key words written in each finger) explain the steps in the planning

process:

WHAT? What do we want to do/achieve? (Objective and Activities)

HOW? How are we going to do it? What are the specific tasks/steps we need to take

to account to accomplish activities? (The process/tasks/steps )

WHO? Who (specific names) will be responsible for each activity/tasks?

WHEN? When will each step take place (specific times, can be in days, months etc)

WHERE? Where will the action take place? (Place)

2. In plenary, brainstorm what a community level action plan should contain. One or more of

the following should be mentioned:

Objective/Activities

Resources

Indicators/Expected outcomes

Timelines

Responsible persons

3. Distribute sample action plan template and discuss each column by providing examples in

the context of community level IYCF/PSNP activity and ask participants if they need more

clarification.

4. Summarise the activity by providing tips for developing action plans and emphasise the

need to guide community level activities with action plans and regularly monitor

performance to adjust and enhance performance.

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What are planning and an action plan?

Planning is a process by which detailed actions/activities are identified and described in a certain

format to address a given problem or achieve a given goal/objective.

It involves identifying and describing:

The problem/gap at hand

Actions needed to address it (What)

Strategies/process/steps/tasks required to realise the actions (How)

The person/organisation responsible for undertaking the actions (Who)

The time period the actions are going to be undertaken (When)

The place where the action is to be undertaken (Where)

An action plan means to organise the different actions into a format to help show a clear

understanding of the type of activities, how they will be done, by whom, when and where. It also helps

to implement the different actions and monitor their implementation in a timely and planned manner.


Tips in developing community level action plan

1. Clearly understand the purpose of the community activity.

2. Consolidate and review relevant information that helps with the planning.

3. Develop a consensus on objectives, activities, desired results and indicators.

4. Identify resources, opportunities, challenges /constraints.

5. Develop strategies to address the challenge and achieve the desired results.

6. Identify and mobilise resources needed.

7. Assign responsibilities.

8. Determine time lines.

9. Establish coordination mechanisms.

10. Determine how to monitor processes.

11. Present draft plans to the broader community if appropriate.

12. Revise plans (if necessary) based on progress evaluation and feed back.

13. Finalise plans in a formal document.

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HO 10 A: Five friends of planning

Activity 10.2: Action plan development. (30 minutes)

Explain to the participants that now they will develop an action plan for their IYCF/PSNP community level activities.

Facilitator presents the key activities of the project that should be included in their action plan.

Then divide participants into groups based on where they came from, as they have to work together after the training, and distribute the Action Plan template to each group.

Explain to them that they must work in their group to identify key activities and key roles that FSTF can do to improve IYCF in his/her community.

Explain that they must think of and identify activities to help to mobilise women, their infants and young children and other relevant community members to improve nutritional status and referral to use services. Allow 20 minutes.

Let each group present the completed action plan to the whole group and facilitate discussion and provide feedback.

Based on the feedback obtained in the plenary, ask each group to revise their action plan, prepare three copies, signed by each member and submit one copy to the project focal person, one copy to Woreda FSTF and one for themselves.

Explain to participants that the action plan will be used to follow up and monitor their progress in implementing community activities on IYCF/PSNP.

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HO 10B: Sample action plan template

The PSNP is underpinned by the following guiding

Activity Strategy for carrying

out activity

Responsible

person

When? Resources needed

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REFERENCES 1. AED/LINKAGES-Ethiopia: ENA Counsellor’s Guide, Using the Essential Nutrition Actions to Improve the Nutrition of

Women and Children in Ethiopia, Including Situations of Emergencies and HIV & AIDS; Revised January 2005

2. Ministry of Agriculture and Rural Development: PSNP Programme Implementation Manual; Addis Ababa March 2010

3. Alive & Thrive: Complementary feeding of children 6-24 months, in service training manual for HEW; December 2010

4. Nutrition Service (AGNP) Food and Agriculture Organization: Short training guide on trials for improved feeding (TIPs) Charity Dirorimwe, Nutrition Education Consultant; April 2007

5. Concern Worldwide Ethiopia: Draft Guideline for conducting TIPs in Dessie Zuria; 2011

6. WHO: Infant and Young child feeding counsellling, an integrated Course Participant Manual and Trainers Guide; 2006

7. ENN: Integration of IYCF support into CMAM; October 2009

8. Alive & Thrive. Infant and Young Child Feeding in Communities: A Rapid Assessment in Tigray and SNNPR, Ethiopia. Addis Ababa, Ethiopia; Alive & Thrive; 2010.

9. Alive & Thrive. Practices, IYCF practices, beliefs, and influences in SNNP region, Ethiopia. Addis Ababa, Ethiopia; Alive & Thrive; 2010

10. Alive & Thrive. Practices, IYCF practices, beliefs, and influences in Tigray Region, Ethiopia. Addis Ababa, Ethiopia; Alive & Thrive; 2010

11. Concern Worldwide-Ethiopia: In Depth Analysis of Dessie Zuria Woreda’s Current Nutrition Situation; June – July 2010

12. Concern Worldwide-Ethiopia: Promoting IYCF within PSNP baseline Survey report Dessie Zuria Woreda; January 2010

13. FMOH: National Nutrition Programme; April 2008

14. FMOH: National Nutrition Strategy; January 2008

15. FMOH: CBN HEW training Guide for HEWs; Revised March 2009

16. FMOH: Training Guideline for Management of SAM at the HP level; July 2008

17. FMOH/FHD, National Strategy for Infant and Young feeding; April 2004

18. FDRE/FMOH: Complementary feeding recipe for Ethiopian Children 6-23 months, A practical cooking and feeding guide: August 2006

19. FMOH: Facilitators guide for Nutrition promoter Training: May 2006

20. Patrizia Fracassi and Lioul Berhanu: Linkages Report; 2010

21. Concern Worldwide-Ethiopia: Startup Workshop Summary Report: Promoting Infant and Young Child Feeding within the Productive Safety Net Programme of Dessie Zuria Woreda, (IYCF-PSNP) project; January 2011.

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